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Full text of "Claudia, a case history of intensive behavior analysis and behavior change"

CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR 
ANALYSIS AND BEHAVIOR CHANGE 



By 

William M. Hartman 



A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL 

OF THE UNIVERSITY OF FLORIDA 

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE 

DEGREE OF DOCTOR OF PHILOSOPHY 



UNIVERSITY OF FLORIDA 
1979 



To my friends and teachers of the science of human behavior, 

Claudia and Hank. 



ACKNOWLEDGEMENTS 

There are so many people to whom I am indebted that in 
thanking some individuals, I run the risk of oversight. Two 
notable omissions are, however, intentional: I have instead 
dedicated this work to them. 

I would first like to thank my committee, Drs. Marc 
Branch, Mark Goldstein, James Johnston, John Newell, Dorothy 
Nevill, and Henry Pennypacker. They provided guidance and 
encouragement in a project that had considerable personal, 
as well as professional, meaning to me. In addition, I am 
indebted to Drs, Calvin Adams and Ogden Lindsley for their 
aid in aspects of design and preparation, and to Ms. Vickie 
Barkmeier for her invaluable assistance in editing and 
preparing the manuscript. 

I would also like to thank my entire family for their 
unfailing love and support. There is simply no way to even 
begin expressing my gratitude to and love for rry parents. 
I can, however, thank my mother for her active interest in 
and help v/ith my professional career, and my father for his 
incredible expenditure of time and energy in preparing the 
entire set of graphics for this paper. 

Families are not limited to those to whom, one is related. 
My thanks to the entire Pennypacker family for the home away 
from home they made for me. 

iii 



There are also two men whose impact on me was profound 
and whoffi I wish to rem.ember here, the late Zelig Sered and 
William Resnick. 

I would like to extend special thanks to a special 
group of people. I am lucky and proud to have been a part of 
the loving, caring team effort that was the STARS Program. 

I am particularly indebted to one person. I would like 
to thank xMs . Lynda Ward, not only for the time and expertise 
she devoted to this work, but also for her support, her love, 
and for seeing mie through. 



XV 



TABLE OF CONTENTS 

PAGE 

ACKNOWLEDGEMENTS ......... iii 

ABSTRACT ' ^^^ 

CHAPTER ONE: CASE HISTORIES AND THE PRESENT STUDY ... 1 

Introduction ^ 

Case Histories ^ 

Definition of Case History 2 

Earliest Case Histories in Child Development ... 5 

Psychological Narratives _ 9 

Quantitative Data, Analysis, and Learning 

Theory -'•'^ 

Behaviorism • -"-^ 

Behavior therapy ..... ^1 

Operant conditioning 12 

Studies of Retarded Individuals ......... 13 

J. M. G. Itard and the Wild Boy of Aveyron .... 16 

Claudia: Rationale for and Technical Aspects of 

the Case History 20 

Rationale ^^ 

Technical Aspects 22 

CHAPTER TWO: CLAUDIA: A CASE HISTORY OF INTENSIVE 

BEHAVIOR ANALYSIS AND BEHAVIOR CHANGE ■ . 26 

Background: Claudia's First Seventeen Years .... 26 

From Home to the Institution 26 

Life at Sunland 27 

The STARS Meet Claudia 20 

The STARS Program at Lilac Cottage 30 

Initial Observations 34 

Rumination Baseline • ^"^ 

Designing the Rumination Procedure 40 

Training Begins ^^ 

Results of the Rumination Procedure 45 

Building New Behaviors I: Eye Contact 49 

Building New Behaviors II: Playing Catch .... 54 

By-products of the Early Training 5 8 

Basic Self-Feeding Skills - 60 

Learning to Scoop • ^^ 

Fine Details of Scooping o2 



PAGE 

Learning to Walk • 6 9 

Preparatory Programs .......... 70 

The First Independent Steps 73 

Rumination Redxix 7 9 

Unmonitored Rumination 79 

Procedural Revision . 81 

Reversal and Return to Intervention 8 3 

Advanced Ambulation Skills 90 

Walking Outdoors 90 

Auxiliary Skills I: Into and Out of Chairs ... 92 
Auxiliary Skills II: Standing Up from the 

Floor 97 

The Daily Constitutional, Part I 100 

The Daily Constitutional, Part II 106 

Auxiliary Skills III: Climbing Stairs . 109 

Auxiliary Skills IV: Crossing Obstacles 115 

The Campus Cafeteria 119 

Getting There . 119 

Eating Skills in the Cafeteria 121 

The Serving Line and Carrying the Tray 12 6 

Final Aspects of Training 130 

Exploring Out the Gate 130 

Expanding the Daily Constitutional 132 

Social Behavior 133 

The Limits of Training 136 

Review of Training Discussed Heretofore 137 

Programs That Failed 139 

Programs Never Attempted ... 141 

Determining the Limits of Training 143 

Saying Goodbye 146 

The Author Leaves the STARS Program 146 

Claudia Leaves Lilac 147 

Final Considerations 152 

CHAPTER THREE: DETERMINATION OF VISUAL THRESHOLD . . . 154 

Method ......... . 156 

Training the Basic Response .... 156 

Discrimination Training 158 

Testing, Retraining, and Retesting 166 

Results 168 

Discussion • I'l 

REFERENCES 1"^"^ 

BIOGRAPHICAL SKETCH 18 3 



VI 



Abstract of Dissertation Presented to the Graduate Council 
of the University of Florida in Partial Fulfillment of the 
Requirements for the Degree of Doctor of Philosophy 



CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR 
ANALYSIS AND BEHAVIOR CHANGE ' 

By 

William M. Hartman 

December 19 79 

Chairman: Dr. H, S. Pennypacker 
Department: Psychology 

The cost, effectiveness, and cost benefit of applying a 
variety of intensive behavior change procedures were evaluated 
in a state residential institution for the retarded. Effec- 
tiveness was measured in terms of appropriate changes in res- 
ponse frequencies; costs were equated with time and money; 
and cost benefit was derived by the cost-avoidance resulting 
from the demonstrated increase in adaptive behavior. The study 
occurred over a period of approximiately two and one half years 
and included over 6000 training and testing hours. The sub- 
ject was a nonambulatory, self-abusive, profoundly retarded 
female adolescent. Training and/or analysis was conducted 
in five areas, as follows: 

Decrease of self-abusive behavior (rumanation) : Analysis 
of diet indicated that rumination frequency was a,t least par- 
tially dependent on liquid density and time of liquid intake. 



vri 



Changes in these parameters reduced rumination rate from 1.2 
to 0.6 responses per minute. Addition of a rumination-con- 
tingent lemon juice squirt, followed by a cheek-hold procedure, 
decreased the frequency to 0.00 3 ruminations per minute. A 
weight gain of 45 pounds accompanied the decrease in rumina- 
tion. 

Ambulation training: The following classes of behavior 
were instated (none were present prior to training) : inde- 
pendent walking, up to one mile per day at over 100 steps per 
minute; independent chair use (into and out of chairs), at 7.0 
times per minute in speeded practice trials; ascending and 
descending stairs, at 25 stairs per minute; crossing obstacles, 
at 6.0 times per minute in speeded practice trials. 

Eating and related skills training: Independent scooping 
with a spoon was increased from 0.6 to 8.0 scoops per minute. 
Use of a cup was taught to terminal performance in practice 
trials of 8.0 correct uses per m.inute versus one or zero 
spills per five minutes. Training in cafeteria tray-carrying 
reduced the frequency with which materials on the tray were 
spilled from five times per minute to about once per minute, 
at which time totally independent tray-carrying was possible. 

Motor skills training: A variety of skills was taught, 
including playing catch, with a terminal performance of 70 
correct throws versus one wrong throw per ten minutes. Tri- 
cycle riding was also trained; assists to steer the tricycle 
were decreased from five to less than one per minute. 



VI XI 



Assessment of visual f unction irx'g: A modification of the 
constant-stimulus psychophysical method was used in a non- 
verbal discrimination task involving a white cube (S+) and a 
white cube with a black circle (S-) . Lifting S+ and deposit- 
ing it in a container resulted in reinforcement, and touching 
S- was followed by a brief timeout. The diameter of the S- 
circle was gradually reduced from 0.40 cm to 0.0 4 cm. From 
the resulting 75 percent correct threshold value of 0.0 8 cm, 
acuity ratio v/as calculated as 20/130 (both eyes) . 

Periodic follow-ups indicated that most major induced 
changes maintained, particularly walking, independent eating, 
reduction in rum.ination rate, and weight gain. 

Discussion included assessment of factors related to 
maintenance of behavior change and a limited analysis of in- 
creased social behavior as a by-product of intensive training. 
In addition, qualitative and quantitative techniques were 
suggested for assessing the relative effectiveness and ef- 
ficiency of training procedures and for determining maximal 
skill levels in retarded persons. 



XX 



CHAPTER I 
CASE HISTORIES AND THE PRESENT STUDY 



Introduction 

This paper is a report of two and a half years of the 
intensive study and training of Claudia, a profoundly retarded 
adolescent living in Sunland Center, Gainesville, Florida. •'- 
The data included in the report were collected routinely as 
part of Claudia's participation in the STARS (Start Training 
Appropriate Responses to Stimuli) Program, a training project 
funded by Public Law (PL) 89-313.^ 

The material chronicles behavior analysis and behavior 
change efforts in a variety of areas — self-abusive behavior, 
motor skills, daily living skills, and determination of visual 
acuity threshold — and covers many specific behaviors. Since 
the analysis and modification of each behavior was highly de- 
pendent on the concurrent existence and rate of many other i 
behaviors, the report is best presented in case history, roughly 
chronological form, rather than as a series of separate be- i' 
havior analyses and behavior modification projects. i 



^Permission to use the data reported herein was granted 
May 26, 1978. A copy of the release form is on file in the 
Training Department Office, Sunland Center, Gainesville, Florida, 

^The contents of this report do not necessarily reflect 
the views of the Department of Health, Education and Welfare. 



The paper is divided into three major sections. Chapter 
One revolves around the concept of the case history, tracing 
the evolution of the case history in psychology and particu- 
larly in behavior analysis. This section considers the rela- 
tionship between behavior analysis and behavior change, and 
concentrates upon reports of disabled (retarded, autistic, 
etc.) individuals. Chapters Two and Three are Claudia's case 
history. As indicated above, the material is presented in 
approximate chronological order. The case history is sub- 
divided according to training milestones, rather than into 
time periods of equal length. Traditionally-labeled sections — 
"setting," "procedure," etc. — are omitted; all information 
that would normally appear in those sections is included in 
the narrative account to permit a more readable text. 

Case Histories 

Definition of Case History 

A case history is an account of the intensive study of 
some portion of an individual's life. It is usually either 
a description of change (rehabilitation) efforts for a problem 
or a set of problems, or is a complete description or analysis 
of a set of target behaviors. When behavior analysis components 
(experimental manipulations designed to establish a functional 
relation among stimuli and responses) are included, the term 
"case study" may be used. However, the two terms are fre- 
quently used synonymously (e.g., Ullman & Krasner, 1965), with 
good reason: It is difficult to establish the point at which 



description of behavior and behavior change ends and t±ie 
experimental analysis of behavior begins (Johnston & Penny- 
packer, in press). For present purposes, several comments 
will suffice to demonstrate that behavior change/behavior 
analysis are best viewed as constituting a continuum; a 
particular case history may include data from any part or 
parts of that continuum. 

The commonest form of treatment described in case 
histories involves instituting a change in the subject's 
environment and observing whether behavior change follows. 
If the behavior changes, especially in the desired direction, 
the therapist is likely to conclude that there is a relation 
between the procedure and the observed change. The experi- 
mental reasoning is weak and clearly belongs at the "behavior 
change" end of the continuum. However, for therapeutic pur- 
poses the goal has been accomplished. The therapist may also 
wish to explore the alleged relation further, for a variety 
of reasons and in a variety of ways. The therapist may, for 
example, want to test the strength of the therapeutic effect, 
examine the degree to which the effect is maintained in 
different situations, and demonstrate necessity/sufficiency 
of various aspects of the procedure. The therapist's acti- 
vities are now shifted toward the "behavior analysis" end of 
the continuum. 

The case studies described below cover a large portion 
of the continuum. The degree to v/hich each m.ay be considered 
analytic depends upon the nature of the data — diary, 



4 

narrative log, observation schedule, behavioral frequency, 
etc. — and upon the "experimental design" employed by the 
author. The designs vary by circumstance, ranging from "I 
wonder what my client will do if I suggest. . .," to highly 
sophisticated and incisive strategies as those described in 
research texts (e.g., Sidraan, 1960; Johnston & Pennypacker, 
in press) . 

No effort will be made to rate the case histories' 
analytic value or quantify the continuum. In fact, many 
histories lack all but the crudest and most inferential data 
and reasoning, but are valuable for other reasons such as 
providing pleasurable reading and, occasionally, inspiration. 

The role of analysis has become crucial for at least 
one group of case history producers and consumers — the group 
included under the rubric of "behavior modification" (Kazdin, 
19 78) . For this group, case histories of the most analytic 
form — studies of individuals conducted explicitly to dis- 
cover the laws of behavior — comprise a portion of the 
experimental literature. In such experimental studies, 
emphasis is generally placed more upon graphic displays of 
data than upon narrative account, but the results may cer- 
tainly be viewed as case histories. In addition, non- research- 
oriented modifiers or therapists regularly integrate various 
levels of analysis into their therapeutic endeavors. The 



amount and kind of analysis is-- or should be — dictated by i 
the needs of the case at hand. 



The following sections provide a sample of the scope 
and flavor of case histories, and a brief discussion of the 
potential and merits of the histories. Heaviest emphasis is 
placed upon the role of the case history in behavior analysis, 
especially in the training of disabled individuals. 

Earliest Case Histories in Child Development 

While earlier accounts of the behavior of individuals 

are available, Tiedmann's (1787/1927) work is recognized as 

"the first attempt to make a series of scientific observations 

on the behavior of young children" (Tiedmann, 1787/1927, 

p. 206). Tiedmann's goal was to provide data for teaching 

"the development of the mind's powers"; he noted that there 

was "a dearth of exact and sufficiently numerous observations 

upon children's souls" (Tiedmann, 1787/1927, p. 205). To 

rectify the situation, he regarded detailed study of the 

individual as the best solution, with the following caveat: 

I grant that what has here been observed [, 

cannot be taken as a general law, since 

children . . . progress variously . . . ; 

but at least it informs us of one among 

the possible rates of progress .... j 

When we shall have several such records | 

it will be possible by means of compari- ■ 

son to strike an average for the common 

order of nature. (Tiedmann, 1787/1927, :. 

p. 206)1 L 

Beginning in 1787, Tiedmann observed and "experimented 

\ 

upon an infant from birth to age two years, six months." His 



Ijohnston & Pennypacker (in press) describe the develop- 
ment of the view that social phenomena are subject to a 
natural law of averages, and the growth of statistics based 
on this view. 



report was completely narrative and chronological, with 

extensive notes concerning the first several days and more ' 

infrequent observations — about one per several months, as 

relevant — thereafter. His data were not quantitative, but 

his observations and "experiments" enabled him at least to 

begin analyzing behavior. For example, in tracing the 

development of the sensation of taste, Tiedmann notes: 

Even the special sensations of taste . . . 
were not yet distinguished (at two days of 
age) .... This appeared conclusively 
on August 25. On account of an indisposi- 
tion the boy was given a medicine of un- 
pleasant taste and pungent odor; he took it 
without any sign of objection, like his 
usual food. . . . [t] hirteen days after his 
birth the boy showed some traces of acquired 
ideas, in clearer sensations and affections 
of his soul. Some medicines were now un- 
willingly taken, with evident reluctance, yes, 
were even spewn forth again, but not immedi- 
ately, rather upon being tasted several times, 
(pp. 208-209) 

Tiedmann frequently strayed beyond the limits imposed by his 
data to draw highly inferential conclusions, looking as he 
was for "proof of the superior original activity of the human 
soul" (p. 211). Nevertheless, his work was a dramatic, early 
demonstration of the potential of detailed study of the 
individual; i.e., the case history. 

Although Tiedmann 's study was perhaps the first published 
attempt at a scientific case history, the educator Pestalozzi 
had published a diary several years earlier (1774) documenting 
his efforts to teach his young son. While Tiedmann was in- 
terested in the description and analysis of various "naturally 
unfolding" behaviors, Pestalozzi 's diary was an early prototype 



of case histories involving the description of individual 
intervention strategies. Although Pestalozzi was not con- 
cerned with detailed analysis of his procedures, he carefully 
observed the effects of instituting the procedures. He thus 
obtained at least a no-intervention vs. intervention analysis: 

I left him no choice between his task 
[boring, unhappily attended reading 
lessons]] and my displeasure with the 
consequent punishment of being confined 
in a room by himself. After this he 
gave way and learned his lessons merrily. 
(Pestalozzi, 1774, in Green, 1912, p. 29) 

Pestalozzi was also aware-- but did not pursue the study — 
of primary reinforcement. He maintained a supply of cooked 
apples which he distributed to his son, Jacques, "now and 
then." Initially, Jacques wanted to eat all of them at once, 
but his father refused, using the opportunity to induce 
Jacques to study, telling him, "if he learnt well I would 
give him some more. He left the spoon alone," and proceeded 
with his lessons (p. 34) . 

Pestalozzi 's diary, among his other works, made important 
contributions to the field of education. In addition to 
providing many examples of effective and ineffective instruc- 
tional techniques (he recognized the value of reporting 
failure as well as success) , the diary v;as a forerunner of 
the many current individual education plans, prescriptions, 
etc. 

Shortly, after Tiedmann's and Pestalozzi 's pioneering 
efforts, Itard published the results of nearly five years 
of studying and training Victor, the "Wild Boy of Aveyron" 



8 

(1801, 1806, translated by Humphrey & Humphrey, 1962). Victor, 
v7ho was probably abandoned at about age three to live alone 
in the forests of France, was the best-known but not the first- 
reported feral child. At least ten such cases were reported 
betv/een the mid-sixteenth and eighteenth centuries, and 
Linnaeus classified them as a distinct human species. Homo 
Ferus (Locke, in Pringle-Pattison , 192 4; Rousseau, translated 
by Masters, 1964). However, the early reports of feral chil- 
dren were sketchy and unreliable; Itard's several publications 
are combined to form the first complete case history of such 
a child. First Developments of the Young Savage (1801) and 
A Report Made to his Excellency the Minister of the Interior 
(1806) combine Tiedmann ' s attempts at scientific analysis and 
Pestalozzi's description of educational intervention, to 
constitute what is arguably the finest case history ever 
written. The work will be considered in detail in a later 
section; it is mentioned here to note its place in the evolu- 
tion of the case history. 

During the remainder of the nineteenth and early twen- 
tieth centuries, case histories similar to those described 
above continued to appear. Darwin (1877) , for example, pub- 
lished A Biographical Sketch of an Infant , a narrative based 
on the diary he kept of his son's first six months. The 
narrative is quite similar in form and content to Tiedmann 's 
earlier work. Singh & Zingg in 19 42 published an account 
of Singh's work in the 1920 's with several feral children, 
and included a review of the earlier feral cases (Hahn, 1978) . 



Diaries and narrative logs thus comprised the earliest 
data of the child development field (Arrington, 1939; Mussen, 
Conger, & Kagan, 1969; Lytton, 1971). Although behavioral 
time-sampling schedules became the most popular method of 
collecting data during the 1930's (Hartman, 1978), the case 
history remained a major vehicle for detailed study of the 
individual. For example, Barker's "psychological ecology" 
was centered around the "specimen record," or "narrative 
account" (Barker & Wright, 1949) . Piaget also used such 
accounts to support his theories of child development, 
although narrative records did not comprise the majority of 
his data (Flavell, 1963). 

Psychological Narratives 

The rise of psychoanalysis created great interest in 
treatment-oriented case histories or "psychological narratives." 
Due to Freud's prolific writing, the case history assumed an 
integral place in psychoanalytic literature (e.g., Freud, 
1955) . Freud published six case histories based upon various 
types of information. "The Wolf Man" was a discussion of 
childhood neurosis, stemming from psychoanalysis sessions 
conducted while the patient was in his twenties. Another 
case history was based upon an autobiography; Freud never saw 
the subject. Freud used the case histories as proof of 
various aspects of his theories and as a setting for theo- 
retical expositions. "Dora" for example, written much like 
a novel, demonstrated the value of dream interpretation in 
analysis (Jones, 1955). 



10 



As the numl^er of psychotherapeutic orientations grew, 
so- did the number of applications of the ca.se history. In 
addition to appearing in professional journals and books, 
case histories and life stories were dramatized and appeared 
in the popular literature/ with appeal to professional and 
public tastes alike. Dibs in Search of Self (Axline, 1964), 
Three Men (Evans, 1966) , Sybil (Schreiber, 1974) , and Children 
with Emerald Eyes (Rothenberg, 1977) are recent examples; 
their style and popular appeal were foreshadowed by Beers' 
autobiographical A Mind That Found Itself (1908). 

Quantitative Data, Analysis and Learning Theory 

Behaviorism . The foregoing case histories are, with 
several exceptions, primarily treatment-oriented and descrip- 
tive. The emergence of behaviorism, in the early 1900 's 
(Watson, 1924) gave rise to a new type of case history-- 
studies of individuals that incorporated, or even focused 
upon, analysis and/or quantitative data. 

Watson and Rayner (1920) , in their famous study of Albert 
and the white rat, recorded trial-by- trial progress in 
conditioning and generalizing fear. Using similar methods, 
Jones (1924) studied and treated another young boy's fear of 
various objects. Jones examined the effectiveness of gradually 
"fading in" the feared stimuli and noted the degree to which 
Peter responded to similar objects not involved in the decon- 
ditioning manipulations. 

Skinnerian psychology (Skinner, .193 8, 195 3) placed 
quantitative studies of individuals firmly within the realm of 



11 

scientific inquiry. Experimental methods and recording 
techniques, developed in the animal laboratory, were soon ap- 
plied to the analysis of human behavior (e.g., Fuller, 1949; 
Azrin & Lindsley, 1956; Bijou, 1955, 1957, 1958) and continue 
to constitute an integral portion of the experimental litera- 
ture (e.g., Barrett, 1965; Ferster & DeMyer, 1965; Findley, 
1966; Emurian et al. , 1978). These purely analytic endeavors, 
published in experimental format, are nevertheless highly de- 
tailed studies of individuals. As such, they may be correctly 
considered case histories, belonging at the "analytic" end of 
the continuum discussed earlier. 

Behavior therapy . People involved in the treatment of 
behavior disorders quickly saw the relevance of the work of 
Watson, Skinner, and other researchers, and applied learning 
principles to clinical practice. In the late 1950 's and 1960 's, 
Wolpe, Lazarus, Eysenck, Shapiro, and others used case studies 
extensively as "proof" of and support for the validity of their 
various behavior therapy theories and techniques (e.g., Wolpe, 
1958; Shapiro, 1966). Shapiro in particular supported the no- 
tion of single-case study for demonstrating therapeutic con- 
trol of behavioral disorders. 

The early case material heavily emphasized treatment and 
did not concentrate upon analysis: No-treatment vs_, treatment 
comparison was the common form of case study. For "proof," the 
therapists relied upon large numbers of cases, or "reproductions" 
of the therapeutic effect. Lazarus (1963) , for example, sum- 
marized the results of 125 cases of treatment of severe neurosis. 



12 

The relative merits of using this fomn of case history 
in lieu of more highly analytic studies, group or single- 
subject design, were hotly debated (especially Breger & 
McGaugh, 1965, 1966; Rachman & Eysenck, 1966). The most 
reasonable conclusion rests upon the degree of analysis 
evidenced by a given case history: The studies reported by 
the behavior therapists did not offer conclusive proof of the 
effectiveness of the therapy techniques employed, but neither 
were the cases irrelevant; they were highly suggestive demon- 
strations that stimulated more analytic endeavors (Oilman & 
Krasner, 1965; Kazdin, 1978). 

Operant conditioning . In addition to practitioners of 
the behavior therapies described above, another group of 
researchers/therapists included by the label "behavior modi- 
fiers" are those who have concentrated their analysis and 
treatment efforts within the realm of operant conditioning or 
Skinnerian psychology. This group, too, has used case his- 
tories extensively for analytic and treatment demonstration 
purposes. The settings, subjects, and behaviors studied 
vary widely. Heaviest concentration has been upon autistic, 
schizophrenic/psychotic, and retarded individuals residing in 
institutions, but home and outpatient settings for studies 
of normal and disabled individuals are not uncommon (e.g., 
Williams, 1959; Rickard, Dignam, & Horner, 1960; Rickard & 
Dinoff, 1962; Ayllon & Azrin, 1965, 1968). 

The studies have ranged from demonstrative, one-phase 
(treatment) -only reports (e.g., Ayllon & Michael, 1959; 



13 

Wolf. Risley, and Mees, ]964) to highly analytic research 
employing multiple reversals and examination of the target res- 
ponse under multiple conditions (e.g., Allen et al., 1964; 
Hart et al . , 1964; Rickard & Mundy , 1965; Rekers & Lovaas , 1974). 
The most common type of case history is the "AB" or no-treatment 
vs. treatment design (e.g., Ayllon, 1963, 1965; Patterson, 
1965; Wolf et al., 1965). The scope of the studies has 
generally been limited, covering one, two, or three target 
responses for periods of about two weeks to a year. 

The salient feature of these case histories is the 
universal use of graphic displays of quantitative data re- 
garding the target responses. WTiether the studies are 
written in experimental or narrative format — experimental is 
the more common — the graphic data displays are generally the 
focus of the reports. The measurement indices vary greatly, 
including cumulative records, tallies ,, frequency , and most 
often, percent measures — percent time engaged in responding, 
percent trials containing a response, etc. The graphic 
displays, or more precisely, the data contained in the dis- 
plays, make these case histories distinctive among the 
histories discussed heretofore in terms of both behavioral 
description and analysis. 

Studies of Retarded Individuals 

Of particular interest to the present report are case 
histories and related analyses of the behavior of retarded 
persons, particularly the profoundly retarded. 



14 



In 1949, Fuller presented the first conclusive evidence 
that profoundly retarded individuals — formerly designated 
"vegetative idiots"-- were susceptible to operant conditioning 
techniques. Fuller's study was not treatrnent-oriented; he 
demonstrated that a simple response, arm-raising, could be 
controlled by the contingent delivery of food. However, the 
implications for the treament of the profoundly retarded 
were enormous — subsequent case histories demonstrated that 
such basic living skills as feeding, ambulation, and other 
motor behaviors could be taught to these persons formerly 
regarded to be comtpletely untrainable (e.g. , Rice & McDaniel, 
1965; Rice., et al. , 1967; Barton et al. , 19 70; Loynd & 
Barclay, 1970). In addition to developing living skills, 
researchers and therapists demonstrated control of many of 
the undesirable behaviors that frequently accompany profound 
retardation: self-injurious behaviors, such as hand biting, 
head banging, and potentially lethal rumination (e.g. , Kanner, 
1957; Lang & Melamed, 1969; Sajwaj , Libet, & Agras, 1974; 
Cunningham & Linscheid, 1976; Harris & Romanczyk, 1976; Iv/ata & 
Lorentzson, 19 76; Becker, Turner, & Sajwaj, 19 78). 

As is true of the studies reported in the previous 
section, case histories of retarded persons range from un- 
analytic to highly analytic. The majority are demonstrations 
that a particular procedure controls a particular response; 
the most common designs are no-treatment vs. treatment (AB) or 
no-treatment vs. treatment, with a reversal (ABAB) . While 
demonstrating a functional relation between a procedure and 



15 



a behavior has been cornmon, fine-grain analysis, such as 
isolating the 'specific elements of a procedure responsible 
for control, is rare (e.g., Horner & Baer, 1978). For 
example, the relevant aspects of overcorrection procedures, , 
popular in controlling self-injurious behavior, are not 
known (cf . , Epstein- et al. , 1974; Foxx & Azrin, 1973; 
Harris & Romanczyk, 1976). Likewise, some data indicate 
that appropriate behaviors emerge as aversive procedures 
decrease the rates of inappropriate behaviors, but the con- 
ditions under which and the degree to which this occurs are 
not well documented (e.g., Risley, 1968; Miller, Patton, & 
Henton, 1971). In comparison, there is clear indication 
that responses punished under one set of conditions may well 
occur at a high frequency in other (no-punishment) settings; 
even severely retarded individuals readily discriminate 
"safe" and "unsafe" conditions in which to emit the target 
behavior (Lovaas & Simmons, 19 69; Rollings, Baumeister, & 
Baumeister, 1977). 

Retardation case histories also evidence the same 
general scope as do other case histories by behavior analysts, 
An "intensive" study might included measuring and modifying 
three responses over the course of several months (e.g.. 
Miller, Patton, & Henton, 1971). There are two notable ex- 
ceptions to this generally limited scope. One is Stoddard's 
(1971) studies of Cosmo, a profoundly retarded microcephalic. 
Stoddard conducted laboratory studies of Cosmo for nearly 
ten years in an exploration of behavior analysis teaching 



16 

techniques. The studies were generally not treatment-oriented 
in that most behaviors were laboratory-specific with no 
attempt to generalized to Cosmo's living environment (e.g., 
visual discrimination; token training) . 

A second exception to the limited scope of case histories 
is Itard's description of the Wild Boy of Aveyron. 

J. M. G. Itard and the Wild Boy of Aveyron 

Although Itard worked with Victor, " L' enfant savage ," 
from 1801-1806, the work is discussed here because of its 
importance to retardation, the experimental analysis of 
behavior, and the development of the case history. First 
Developments of the Young Savage (1801) and A Report Made to 
his Excellency the Minister of the Interior (180 6; both 
translated by Humphrey and Humphrey in 1960) together form the 
first case history in behavior modification (Lane, 1976). 
As will be seen, the work differs from modern behavior 
analysis case histories in two respects. First, there is no 
graphic display of quantitative data; Itard's reports are in 
narrative form with all "data" described in the text. Second, 
the technical terminology obviously differs from today's. 
Nevertheless, The Wild Boy of Aveyron is arguably the finest 
case history ever written in terms of its scope (duration of 
training and range of behaviors trained) and in terms of the 
full natural integration of training and behavior analysis 
to maximize the subject's progress. 

Victor was captured in the forest of Aveyron and 
brought to Paris in 1800. Authorities, especially Pinel, 



17 

estimated his age to be about twelve years and diagnosed his 

condition as incurable idiocy (Lane, 1976). Victor initially 

created a professional and public sensation in Paris, but the 

excitement soon abated since the boy was filthy, unmanageable, 

and "differed from a plant only in that he had, in addition, 

the ability to move and utter cries" (Itard, 1806/1960, p. 54). 

Itard, however, was struck by Condillac's comment that earlier 

feral children seemed to possess the intelligence required by 

their environments. Based upon this observation and upon the 

works of Locke and Rousseau, Itard reasoned that Victor was 

largely a product of his environment and that "he had only to 

find the proper social and physical education in order to 

supply the mental content that would make the boy a normal 

human being" (Itard, 1806/1950, p. viii). 

Realizing that the weight of current medical opinion 

V7as against him, Itard requested and received permission to 

care for and train Victor. If the authorities were correct 

and Victor proved untrainable, Itard hoped to at least provide 

data to speak to the heredity vs. environm.ent question. He 

surmised that, 

someone who, carefully collecting the history 
of so surprising a creature, would determine 
what he is and would deduce from what he lacks 
the hitherto uncalculated sum of knowledge and 
ideas which man owes to his education. (Itard, 
1806/1960, p. xxiii) 

Itard completely, successfully fulfilled neither aim: 

Victor never became a "normal human being," nor did Itard 

find a definitive answer to the nature-nuture question. But 



18 



Victor did acquire a behavioral repertoire that far exceeded 
the predictions of Itard's contemporaries, and Itard did 
illuminate the role of the environment in shaping behavior. 
In so doing, Itard changed the course of education, particu- 
larly for disabled persons. He placed the emphasis of edu- 
cation upon the individual, letting his pupil's behavior 
determine the course of instruction at every step along the 
way. The business of education, he felt, was "detecting the 
organic and intellectual pecularities of each individual and 
determining therefrom what education ought to do for him and 
what society can expect from him" (1806/1960, p. 50). 

Itard's description of his work with Victor is fas- 
cinating and educational to the modern reader in a number of 
respects. Not the least of these is the way that Itard 
repeatedly reasoned out and applied behavior management 
principles. For example, one of Victor's earliest pleasures 
was going out to eat in town. Itard immediately saw the 
value of establishing reliable cues for this event and using 
them to reinforce behavior: 

I was careful to precede our expeditions by 
certain preparations he would notice; these 
were to enter his room about four o'clock, 
my hat upon my head, his shirt folded in my 
hand. These preparations soon came to be for 
him the signal of departure. I scarcely 
appeared before I was understood; he dressed 
himself hurriedly and followed me v/ith much 
evidence of satisfaction. I do not give 
this fact as proof of a superior intelligence 
and there is not one who will not object that 
the most ordinary dog will do at least as 
much. But in admitting this intellectual 



19 

equality one is obliged to acknowledge 
a great change, and those who saw the 
Wild Boy of Aveyron at the time of his 
arrival in Paris, know that he was very 
inferior on the score of discernment to 
this most intelligent of our domestic 
animals. (p. 23) 

Itard was aware of and used a wide range of behavioral 

techniques, now labeled primary and secondary positive and 

negative reinforcement, fading, chaining, shaping, and 

punishment. He carefully observed the connection between his 

procedures and Victor's behavior, and was able to evaluate 

both his successes and failures. He was, for example, not 

surprised when his initial attempt to punish Victor's food 

stealing backfired: 

In order to repress this natural propensity 
towards thieving, I made use of chastise- 
ments applied during the very act. I 
reaped what society generally does reap 
from terror of its corporal punishments, 
namely, a modification of the vice rather 
than a real correction of it. Victor 
stole with cunning what until then he had 
been content to steal openly. (p. 93) 

Of all Itard 's contributions, perhaps the greatest was 

the way he used Victor's behavior to restructure continuously 

the training sequences. He invariably based a particular 

training procedure upon Victor's responses to earlier 

procedures. Into this scheme he skillfully incorporated 

true behavior analysis, teaching himself the laws of behavior 

and using the results of the analyses to remove obstacles 

to Victor's progress. While teaching Victor to match objects 

with pictures, for example, Itard realized that his original 

teaching device might well be inadequate: the pictures v;ere 



20 



in a fixed order and Victor might thus be responding to the 

order rather than to pictorial aspects of the stimuli: 

To reassure myself I changed the respective 
positions of the drawings and this time I 
saw him follow the original order in the 
arrangement of the objects without any al- 
lowance for the transposition. As a matter 
of fact, nothing was easier than for him to 
learn the new classification necessitated 
by this change, but nothing more difficult 
than to m.ake him. reason it out. His memory 
alone bore the burden of each arrangement. 
I devoted myself then to the task of neu- 
tralizing in some way the assistance he 
drew from it. I succeeded in fatiguing his 
memory by increasing the number of drawings 
and the frequency of their transpositions. 
... I soon had material proof by experi- 
menting with the transposition of the 
drawings, which v^as followed on his part 
by the methodical transposition of the 
objects. (pp. 39-40) 

Itard's documentation of the extensive changes he 

produced in Victor thus stands as a model case history for 

behavior analysis and behavior change. After five years of 

work and despite some limits he could not exceed ( e.g . , he 

failed in his numerous attempts to teach Victor to speak) , 

Itard had succeeded in transforming a savage into a civilized 

adolescent. From his behavioral methods and his continuous, 

informal analysis of the effects of his procedures came a 

model for training the untrainable. 

Claudia; Rationale for and Technical 
Aspects of the Case History 

Rationale 

There are several reasons for writing Claudia's case 
history. The work is intended to fill a gap in the literature 



21 



of behavioral analysis and behavior change. ■ Itard wrote a 
treatment-oriented case history of still-unparalleled scope 
and detail. Modern behavior analysts and therapists have 
added precise, quantitative measurement, graphic displays 
and, occasionally, sophisticated scientific inquiry methods. 
The scope of these recent efforts has, however, been far 
more limited than Itard' s. The present case history is a 
combination of these aspects. It is a case history of train- 
ing and analysis spanning two and a half years and covering 
virtually every relevant aspect of the subject's life, with 
each training sequence and subsequence guided, evaluated, 
and documented by direct quantitative behavioral measurement. 
Its scope is necessarily more limited than that of Itard' s 
undertaking; likewise, every procedure employed and response 
trained was not subjected to as intense an analysis as has been 
seen in the most analytic modern case histories, with an 
exception: One aspect of Claudia's training was a largely 
analytic endeavor — the determination of her visual threshold. 
Since this activity's emphasis was more analytic than 
treatment-oriented, the results are presented as a separate 
section. 

Claudia's case history is the result of the juxtaposi- 
tion of an individual in desparate need of intensive training 
and a federal grant, P. L. 89-313, that mandated such in- 
tensive training. The author was thus able to integrate 
direct behavioral measurement and formal and informal be- 
havioral analysis techniques to do what he could to help Claudia. 



22 



Technical Aspects 

As indicated earlier, all data reported herein were 
recorded routinely as part of Claudia's training. In this 
sense, the measurement, training, and analysis techniques 
used with Claudia were no different than those afforded the 
fifty-plus other clients trained by the STARS Program. 
Claudia merely received longer and more intense training 
than her peers, as she was the first client accepted into 
the program and her severe rumination necessitated extra 
training. 

The data are primarily behavioral frequencies reported 
in responses per minute, v/ith several exceptions, such as 
weight recordings. ■ The data were recorded by the author 
and by full-time STARS Program employees? all data collection 
procedures were monitored by the author and other super- 
visory STARS staff. With the exceptions of baseline and 
other "hands off" periods, data collection generally occurred 
during the actual training session — trainers used response- 
counters and stopwatches to record the behaviors in-session, 
rather than recording in pretest-posttest fashion. To 
maximize the accuracy and usefulness of the data, most res- 
ponses recorded either produced "behavior products" (see 
Johnston & Pennypacker, in press) or else were discrete and 
unambiguous. The staff thus obtained accurate data with no 
disruption of the training sessions, 

STARS data, including Claudia's, are generally recorded 
on the Standard Behavior Chart (Lindsley, 196 8; Pennypacker, 



23 



Koenig, & Lindsley, 1972). Figure 1 is a typical chart from 
Claudia's training folder and represents the core of STARS 
record-keeping and training-progress procedures. The trainer 
conducting the session recorded the data both on the chart 
and in numeric form on a separate sheet. Supervisory staff 
checked the charts for accuracy on a monthly basis. Other 
records, such as attendance sheets and Sunland campus behavior 
checklists, were maintained, but the behavior charts account 
for the overvrhelming majority of STARS client information. 
Figure 1 highlights conventions necessary to interpret the 
data reported in the following sections. The labels at the 
bottom of the chart are self-explanatory. Also note that 
data are recorded by calendar days, rather than by successive 
sessions; the advantages of displaying data against a real 
time dim.ension are well-documented elsewhere (see Pennypacker & 
Johnston, in press). The primary data are response -frequencies , 
in responses per minute. Dots (•) generally represent correct 
or appropriate responses, the frequency of which trainers 
attempted to increase. "X's" generally represent incorrect 
or inappropriate responses, targeted for decrease. Exceptions 
are noted when relevant. Dashes (-) are "record floors" and 
denote the reciprocal of the amount of time during which 
data were collected. Frequencies of are noted by placing 
the data point directly below the record floor. Since the 
frequency scale (ordinate) is logarithmic, the combination 
of frequency and record floors preserve the entire record — 
the distance on the log scale between the record floor and 
the 1/minute frequency line is the recording time in minutes; 



24 






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the distance between the record floor and its corresponding 
behavioral frequency is the response-count. "Phase lines," 
the vertical bars betv;een sets of frequencies, denote changes 
in procedure or other environmental changes. 

The charts in the case history have been slightly 
modified for greater clarity. Horizontal (days) and vertical 
(frequency) axes are identical to those on the Standard 
Behavior Chart, but the grid has been removed. All charts 
have been reduced to conform to editorial requirements. The 
charts are otherwise identical to those used and updated 
daily in routine client- training operations. 



CHAPTER II 

CLAUDIA: A CASE HISTORY OF INTENSIVE BEHAVIOR 

ANALYSIS AND BEHAVIOR CHANGE 

Background; Claudia's First Seventeen Years ^ 

From Home to the Institution 

Claudia was born in Jacksonville, Florida, in November, , 
1958, a healthy seven pounds, three ounces. Her mother had 
had phlebitis during the pregnancy, but no other complica- 
tions or diseases were noted. There was no family history 
of retardation. 

At age tv;o months, Claudia appeared to be allergic to 
milk, but was otherwise healthy. Her parents began to 
worry at three months: she was still healthy but seemed to 
be hyperactive and they noticed that her eyes were divergent 
and her tongue abnormally large. A month later, the doctor 
noted delayed bone development, but it was not consistent 
with cretinism. Her waking EEC was nor-mal and several tests 
for PKU produced negative results. 

The parents continued to be upset. During the following 
several months they observed that Claudia neither reached for 
objects nor held her bottle. She did seem to notice people 



^The information in this section was culled from ad- 
ministrative, medical, and cottage records. Details of 
Claudia's early training are sketchy and unreliable; hence, 
only the barest facts are presented here. 

26 



27 

and things and laughed when her parents played with her, but 
she did not "socialize" very often. Her movements were jerky 
and the large tongue was continuously out. 

At seven months, the parents insisted on a diagnosis. 
Neither PKU nor cretinism was the problem, responded the 
doctor, but Claudia was probably retarded. She was developing 
slowly, but not excessively so. 

Several months passed, and doctor and parents realized 
the child was definitely retarded. They applied for Claudia's 
admission to one of the Sunlands, Florida's retardation in- 
stitutions. The Sunlands were full, and Claudia was put on 
a waiting list. Eight months later she was re-evaluated and 
considered for placement at either the Gainesville or Orlando 
Sunland. Although she could walk only with complete support, 
Gainesville was the appropriate site: the doctor felt she 
would be walking unassisted within three years, and openings 
at the Orlando Sunland were reserved for cases with more 
severe ambulation problems. 

In 1960, at age eighteen months, Claudia became one of 
the many "retardation, cause unknown" residents of Gainesville 
Sunland. 

Life at Sunland 

There is no record of formal training provided for 
Claudia during the next thirteen years. This is not surprising. 
The institution was overcrowded and woefully underfunded. 
Maintaining basic living requirements for the residents 



28 



devoured most of the budget; the remaining training monies 
had to be spent on the highest level residents, those able to 
benefit from extant teaching and therapy technologies. For 
the lower functioning residents, including Claudia, little 
could be done; even had training funds been available, these 
residents appeared to be untrainable. 

Claudia was definitely, as the higher level clients put 
it, a "low grade." Her mental age at admission was six 
months, I.Q. 32; four years later she tested at mental age 7.4 
months, I.Q. 9 CCattell Intelligence Tests). Subsequent 
attempts to test her using the Stanford-Binet were recorded 
as "FTI" (formal testing impossible) , and she was classified 
at the lowest level on the Adaptive Behavior Scale. In short, 
she was growing older but developing no new behaviors. 

In 1973 she was re-diagnosed as Down's Syndrome. The 
diagnosis was only temporary — tests revealed that her 
chromosomes were normal. Unbeknownst to her, she was again 
"profoundly retarded, cause unknown." 

That same year, reports of self-injurious behaviors 
appeared in Claudia's records. None of the behaviors — 
chewing fingers and toes, occasional head banging, and 
rumination (regurgitating and reswallowing food) — were 
present when she v/as admitted to Sunland. There is no clue 
as to how or why the behaviors emerged. 

Shortly thereafter, some formal programming began. 
Her records state that she was being trained in "self-help 
skills," but there is no account of the regularity, intensity. 



29 



or nature of the training. No skills development was recorded. 

During the same period, Claudia was assigned a foster 
grandparent, Julia. The foster grandparent program provides 
elderly people a small supplemental income and was designed 
to give the lowest level clients personal attention and a 
chance to get outdoors for several hours each day. Although 
structured training is not necessarily part of the program, . 
a grandparent is often a client's only source of special 
attention. Julia thus became a major figure in Claudia's 
life, appearing five days a week to take Claudia out of her 
cottage in a wheelchair to tour the grounds or sit in the sun. 

In 1974, a physical therapist examined Claudia, now 15. 
She had never learned to walk, nor could she learn: both feet 
were severely turned down and inward at the ankle. She had 
learned instead to "scoot," as many clients do; sitting up- 
right, she pulled herself forward with her feet, pushing with 
her hands. She was admitted to the hospital for corrective 
surgery. The triple arthrodesis operation was performed 
without complications, and Claudia returned from the hospital 
physically capable of walking. But she did not walk. There 
was no one to teach her. 

A year later, in July, 1975, Claudia fractured her left 
tibia. She was placed in the hospital, and there she remained 
for several months so that the fracture could heal. During 
her stay in the hospital, her rumination drastically increased. 
When she returned to Lilac Cottage in November, she weighed 
forty-nine pounds, down from her previous high of seventy- three, 



30 



This was Claudia as 1975 drew to a close. She was 
seventeen, fifty-six inches tall and weighed forty-nine 
poxinds. Unable to walk, talk, or in any way care for herself, 
she had developed no new behaviors during her fifteen and a 
half years at Sunland, except, of course, chewing her fingers 
and toes, banging her head, and ruminating; the last was 
slowly killing her by malnutrition. 

The STARS Meet Claudia 

The STARS Program at Lilac Cottage 

In late 19 75, federal funds were released to open a new 
training program at Sunland. Six of us were hired to create 
the "behavior modification component" of grant PL 89-313. 
Our grant specifications were flexible; we were to build a 
staff of seventeen to work on an individual basis with no 
more than thirty- five profoundly retarded clients under 
twenty-two years of age. Training was to occur in the areas 
of motor, self-care, and social skills; that is, we were to 
be behavioral jacks-of-all- trades. 

Our supervisor selected Lilac Cottage as the training 
site (Fig. 2). It contained girls' and boys' wings and was 
reputed to have the campus' highest proportion of appropri- 
ately-aged "untrainables"— multiply handicapped, aggressive, , 
and self-abusive clients who needed individual, intense 
training that other programs could not provide. Funds to hire 
the remainder of our staff were temporarily "frozen" and 
money to open our training building was not yet released; so 



31 




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32 



a week before Christmas we opened our office in the ladies 
lounge at Lilac and went to meet our young charges. 

Going first to the girls' wing we discovered that the 
stereotype of institutions was perhaps not just a stereotype, 
The doors v;ere locked to prevent ambulatory clients from 
running or wandering away. Within, we found drab concrete- 
block-and-tile walls and bare floors; no bright colors or 
decorations or toys relieved the monotony. As miuch as the 
physical layout was typically institutional, the clients 
were even moreso: thirty girls, most of them lying or 
crawling on the floor, several v^ho were ambulatory wandering 
aimlessly or coming up to grab at us. All of them were 
dressed in ragged clothes or ripped gowns. Clothing was for 
shredding and toys for breaking-- any free object was for 
mouthing and eating. We had tried to choose a population 
in need of training. Clearly, we had chosen correctly. 

Since there were thirty girls, and twenty-five boys in 
the other wing, and our enrollment limit was thirty-five, 
our first task was forming a list of priority clients. Test 
scores and profiles were of limited value as the clients 
ranged from low-I.Q. to untestable and most were labeled 
profoundly retarded. The most obvious way to begin our list 
was to ask those who best knew the clients-- the cottage 
parents, or residential care staff, whose job was to bathe, 
diaper, dress, feed and otherwise care for the clients. 

They laughed at our first request. All the children 
needed anything we could give them. But yes, there was one 



33 

girl about whom they were especially concerned. Claudia 
had been ruminating more than ever, and they were worried 
about her. 

They pointed her out to us. From a distance she was 
not remarkable, one of the smaller figures in white, laying 
on her back with knees tucked up about her chest. Walking 
over and sitting down beside her, we understood the cottage 
parents' concern. Her knees were huge compared to her tooth- 
pick legs, her arms were skinnier still, and her ribs showed 
clearly through where her gown was ripped. She had shoved 
about six inches of a diaper into her mouth and periodically 
made a smiall gagging noise, following which a milky vomitus 
appeared in her mouth. Half the substance ran down her chin 
onto the diaper and gown; she manipulated the remainder with 
her large tongue, turning it over while chewing on the diaper. 
After about twenty seconds, she sv;allowed and repeated the 
process. 

It was difficult to determine whether Claudia was 
attending to us. Her eyes diverged and we couldn't ascertain 
where or if she was focusing. In any case, she made no 
attempt to reach for us and altered neither her position nor 
her ruminating routine. She evidenced no awareness of our 
presence. 

We examined the remainder of our potential clients and 
retreated to our office to begin building our program. 



34 

Initial Observations 

We six were young, fresh, eager — and naive — and in no 
mood to await a "go" signal from the state. We had no budget, 
nor could we hire trainers, but we could prepare our record- 
keeping systems, programming procedures, and the like. And 
we could get to know our kids. 

Although there was a campus cafeteria, the residents of 
Lilac and other locked cottages did not attend. Food was 
delivered by truck to these cottages. The cottage parents 
dished it and took it on carts to the living wings. At meal 
time, we went to the wings and helped feed the clients. We 
discovered which clients possessed which skills, learned to 
diaper them, played with them, and wondered about the job 
we were taking on. 

We also knew at least one client with whom we would be 
working, and obtaining a baseline record of Claudia's rumina- 
tion became our first official project. Designing the data 
collection and recording procedures became my responsibility. 

My first activity was to observe Claudia's feeding 
procedure and get a closer look at her rumination. The 
feeding routine rarely varied. Claudia's diet consisted 
entirely of "blend," or pureed vegetables, meat, etc., and 
Sustacal. Blend was given to clients who didn't chew, and 
the Sustacal, a nutrient-rich milkshake-like liquid, was 
prescribed for Claudia to com±)at her rumination-induced 
weight loss. When the food cart arrived at the wing, a 
cottage parent would feed Claudia in whatever position she 



35 

was to be found, usually on her back on the floor. The 
blend was served in twelve ounce bowls and the cottage 
parents fed it to her in a tablespoon as fast as she could 
swallow it, about one swallov; every five seconds. Following 
the blend, the cottage parent sat her up and fed her a cup 
of Sustacal, which she eagerly accepted. Although she 
wrapped her hands around the cup, she needed help in holding 
it and had to be slowed down-- left to her own devices, she 
would open her mouth v/ide and turn the cup upside down, 
spilling most of the liquid. The entire procedure took less 
than five minutes. As the cottage parent moved on to feed 
another child, Claudia commenced ruminating. After watching 
the procedure for several meals, I began feeding her. I was 
uncomfortable feeding her at her accustomed rate, but this 
was my first baseline and I didn't want to disrupt it, and 
Claudia certainly didn't object. 

During these meals, I was happily forced to correct an 
initial impression. The girl was not entirely unaware of her 
surroundings. True, most of the time she attended to nothing, 
but when the food cart arrived, she looked toward the door. 
Upon spotting the cart, she balled up her hands and rubbed 
her eyes and nose, making excited gurgling noises. If she 
was not first to be fed, she scooted over to the cart, looked 
up at it and continued her noisemaking until it was her turn 
to eat. If and v/hen we could control the rumination, we 
obviously had a powerful reinforcer for other training. 



36 

I soon discovered that food was not the only thing that 
commanded Claudia's attention. Monday through Friday, at 
ten o'clock, the foster grannies arrived. Claudia looked as 
they entered the cottage, and she was clearly able to dis- 
criminate her granny, Julia. The hands balled up and she 
rubbed her eyes and nose; she watched closely as Julia col- 
lected a sweater and wheelchair for the daily outing. Once 
in the wheelchair and out the door, Claudia calmed down again, 
ruminating and attending to little around her. But at least 
we were certain that she enjoyed leaving the cottage and that 
she could discriminate the source of this pleasure. 

Watching Claudia ruminate as she went out with Julia 
piqued my curiosity. She seemed to enjoy going out, and it 
was her only break from Lilac, yet the ruminating continued. 
Before beginning systematic data collection, I couldn't re- 
sist playing a little, trying to find an activity that would 
reduce the rumination, I talked to her and, poor thing, sang 
to her, sat her up and played with her hands, but without 
result. I stood her up and v^alked her around the cottage. 
She was capable of walking with complete physical assistance, 
but she ruminated as well standing as she did on her back. 
The cottage parents said she liked balls but had no chance 
to play with them as they were among the other clients' 
favorite objects to tear and eat. I produced a ball and she 
becam.e excited, bouncing it and even attempting to keep other 
clients from grabbing it. Here was yet another potential 
reinforcer and further evidence of intelligence and motor 



37 



control, but still no help for the problem at hand. Ruminating 
and bouncing the ball were not at all incompatible. 

So much for clever ideas. It was time to quantify the 
problem and explore it carefully. But we had learned much from 
these first encounters. Claudia responded to things and 
people around her. Perhaps eventually we could do more than 
try to stop the rumination. 

Rumination Baseline 

We were in a hurry and wanted to do everything at once. 
We had arrived at Lilac two days earlier and were simultane- 
ously trying to get acquainted with our clients, develop 
assessments, set office policies, and wrest our grant money 
and training positions from the state. Nov; Claudia had 
caught our attention. We needed to collect the data necessary 
to make our first training decisions without disrupting our 
grant start-up activities. 

As we had neither staff nor time to continuously monitor 
Claudia, we chose a sampling scheme. At breakfast and lunch 
one of us fed her in the usual manner. Immediately after the 
meal, the staff member stood back and counted the ruminations 
for five minutes. A staffer returned for five minutes each 
half hour thereafter until no ruminations were observed in 
two successive samples. The rumdnations were easy to count, 
as the gagging noise was clear, the vomitus easily visible, 
and chewing was pronounced following each response. 

• The rumination followed a regular pattern (Figure 3a) . 
Immediately after eating, Claudia ruminated about three times 



38 




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39 



per minute and did so for about an hour. Thereafter, the 
frequency gradually decreasedf tapering off to near-zero 
three to four hours after the meal. 

We knew that actual training could not begin until well 
after Christmas. We had yet to hire our staff and once 
hired, they had to endure two weeks of orientation and 
inservice work. We also knew that Claudia was a heavy ru~ 
minator — her physical condition well attested to it — and 
we could see no sense in belaboring the obvious by collecting 
weeks of "uncontaminated" baseline. We couldn't train 
Claudia but we could manipulate her diet and observe the 
effects on rumination frequency. 

The Sustacal was a likely place to start. Although the 
doctors had prescribed it to keep her alive, we were struck 
by the similar appearance and viscosity of the nutriment and 
the ruminative vomitus. In the ensuing weeks we fed Claudia 
her blend and Sustacal separately; blend an hour before 
Sustacal (Figure 3b) , Sustacal a half hour before blend 
(Figure 3c) , and no Sustacal until food-induced ruminating 
had ceased (Figure 3d) . Vie returned to the original baseline 
condition and took stock (Figure 3e) . Although the data were 
not convincing, Sustacal seemed to induce miore rumination 
than did the blend. 

We called the rounds nurse and obtained permission to 
replace the Sustacal with water and jello for several days. 
We were encouraged by the result (Figure 3f ) . Ruminating 
after blend continued, but the water and jello, given an 



40 



hour previously, induced little rumination. Fearing the 
consequences of removing the extra nourishment from Claudia's 
diet, we returned to our original baseline condition and 
began planning training procedures. We had never succeeded 
in decreasing the overall rumination frequency below one per 
two minutes (Figure 4) , but we had demonstrated to ourselves 
that we could induce behavior change in our clients. It was 
a heartening fact to those of us new to the field. 

Designing the Rumination Procedure 

While we were manipulating Claudia's diet, the state 
released our training positions. We hired our staff and 
arranged our schedule. Since decreasing self-abusive be- 
haviors was to be a training priority, we devised staggered 
shifts covering twelve hours per day, seven days per week. 
In this way, clients chosen for intensive training could be 
monitored during miOst of their waking hours, including all 
m.eal times, and there would be no need to base training 
decisions upon small behavioral samples. Claudia and Tammy, 
a girl who had pulled out most of her hair and slapped her 
face severely, were to be the clients to receive twelve-hour- 
daily training. 

As we awaited our trainers' return from their orientation 
activities, we assessed the results of Claudia's baseline and 
considered possible procedures for decreasing the rumination. 
We wanted first to restructure the mealtime environment. 
Even though Claudia had demonstrated that she would ruminate 



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V7herever she found herself, v^'e thought that ^ more closely 
controlled setting than the floor of the cottage day room 
would foster more effective intervention. Our program owned 
several pieces of equipment purchased with early grant 
funds. One of the purchases was a small wooden relaxation 
chair commonly used by physical therapists. It was perfectly 
suited to our needs. The adjustable head rest and clip-on 
tray would allow us to feed Claudia in an upright position 
and would restrict her movements without discomfort. We 
could watch her closely for post-meal rumination. The ap- 
paratus was mounted on wheels, giving us the option of 
feeding her in the bedroom area or hall, away from her usual 
location without having to drag her into and out of a 
wheelchair. 

We also agreed that it would be wise to slow down her 
eating. Most of the clients ate rapidly, whether feeding 
themselves or fed by the cottage parents; the fast eating 
did not seem to induce rumination. Still, Claudia did not 
rumiinate while she ate and perhaps increasing the duration 
of the meal and decreasing the rate of food intake might 
help slow the rumination. We watched one another in the 
campus cafeteria and concluded that one bite per fifteen 
seconds -v^as a reasonable rate. 

The Sustacal posed a tricky problem. Our data suggested 
that Claudia ruminated less without it, yet it constituted 
a major portion of her nourishment and possibly was keeping 
her alive. While we pondered the medical and financial 



feasibility of various powdered food additives, one of the 
cottage parents offered a far simpler solution. Why not mash 
peanut butter and jelly sandwiches into the blend? The result 
might not be esthetically pleasing, but neither was the blend 
alone, and Claudia was hardly a gourmet. The peanut butter 
was rich in protein, the whole sandwich might put weight on 
her, and the thick, gooey product certainly looked harder to 
ruminate than did Sustacal. The rounds nurse readily granted 
approval. We could eliminate the Sustacal, replacing it 
with our concoction. Water and jello before the meal would 
ensure adequate liquid intake. We would be alerted to any 
problems arising from the new diet, as we had been weighing 
Claudia almost daily since data collection had begun. 

We were not satisfied. Our planned procedure v/ould 
probably reduce the rumination but almost certainly not stop 
it. We could foresee a temporary decrease in the rumination 
frequency, followed by a gradual increase as Claudia adjusted 
to her new diet and feeding environment. Any other training 
we might try would be hampered by and possibly enhance the 
rumination. We therefore sought assistance from published 
cases of rumination treatment. 

We located two strategies, response-contingent electric 
shock (Lang St Melamed, 19 69) and response-contingent squirts 
of lemon juice (Sajwaj, Libet, and Agras, 1974). Shock was 
out of the question. No one had ever systematically tried 
to stop Claudia's rumination, and to begin with such a painful 
procedure would be irresponsible and unfair to Claudia. In 



44 

addition, Florida's retardation system operated under a set 
of behavior xnanagement guidelines that clearly forbade the 
use of shock. 

Using lemon juice was feasible. A trainer could use a 
laboratory wash bottle to squirt a small amount, one cc or 
less, onto Claudia's tongue each time she attempted to 
ruminate. The attempts were easy to spot. The gagging noise 
reliably preceded each appearance of the vomitus and we could 
thus "catch her in the act," increasing the likelihood of 
our success. 

Our final preparatory step was to present our baseline 
data and planned procedures to the campus behavior management 
committee. At the time, even using lemon juice was of ques- 
tionable status in the behavior management guidelines and 
required the approval of campus administrators and consulting 
professionals. Moreover, behavior modification was a newcomer 
to the campus and its practitioners were closely monitored. 
Permission was granted and we were ready to begin. 

Several years later, a colleague asked me why — after I 
had independently assessed at least several elements of our 
procedures during those first weeks — I chose a "kitchen 
sink" treatment. The relaxation chair, the spaced feeding, 
the diet changes, the lemon juice,' all at once; it was 
hardly a systemiatic approach to the problem. Granted, it 
was not. But it was our program's first project and v;e were 
testing our competency as behavior change agents. For the 
Sunland campus, it was a test of a new kind of training. 



45 



intense, individualized, and based directly upon behavioral 
data. Most importantly, it was our chance to help Claudia. 
She did not know us; we had done little except observe her 
rumination. But we were getting to know her and wanted to 
help. We planned to use every tool at our disposal to do so. 

Training Begins 

Results of the Rumination Procedure 

On February 5th, Claudia ate her breakfast as she 
usually did, on the day room floor. She spent the morning 
ruminating while Marsha — the trainer I assigned to Claudia — 
and I passed the time fretting, pacing and reviewing pro- 
cedural details. At lunch time, Marsha brought in the 
relaxation chair. We seated Claudia and wheeled her into the 
bedroom area. Marsha placed herself opposite Claudia and 
arranged response counters, stop watch, the gooey mess that 
was lunch, and the wash bottle of lemon juice. The feeding 
went smoothly and we even observed an extra benefit. The 
sticky peanut butter, harder to swallow than blend, helped 
pace the food intake. Claudia was hardly fazed by our tension 
and the nev7 setting and diet. Soon after lunch we heard the 
first gag. Marsha was ready and delivered the lemon juice 
accompanied by a stern, "No, Claudia!" The intervention 
startled Claudia and she jerked her head away. She ruminated 
again, and again Marsha was ready. The attempts to ruminate 
dropped abruptly and within an hour we were able to take her 
out of the relaxation chair. We seated her in the cottage 



46 



lobby- to watch her and be ready with the 'lemon juice until 
v;e were sure ruminating had ceased for the afternoon. 

At dinner we repeated the procedure and were again 
successful. Claudia had begun the day ruminating at her usual 
rate of one to two per minute. With our procedure in place, 
the rate dropped to about one in seven minutes, an eightfold 
decrease. We went home that night elated but concerned. 
Would the effect last or was it merely due to the novelty 
of the procedural barrage? 

The next day indicated that it was not. The ruminating 
rate remained low. After breakfast, trainer and lemon juice 
accompanied Claudia and Julia on their daily excursion. 
Julia had watched Claudia vomiting herself to death and had 
helped us during baseline data collection. She and the other 
foster grandparents shared our excitement. 

On the third day, the ruminating rate declined to one in 
twenty minutes; by the fourth day it was one in fifty. Within 
a week, Claudia had gained five pounds and was ruminating at 
one one-hundredth her original rate. The rate stabilized 
(Figures 5, 6a). Within two months we were able to give her 
her liquid after meals, with no increase in rumination. 

With the rumination under control, Susan, Claudia's 
morning trainer, decided to find out v/hat Claudia liked to eat. 
We had purchased a variety of candy and snacks for the clients 
and Claudia vjas entitled to her share. I arrived at work 
one morning to find Susan upset. If Claudia had to put up 
with the unsightly blend because she couldn't chew, why was 



47 






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she so adept at crunching potato chips? I didn't know. 
Neither did the medical staff, so we replaced the blend with 
regular meals , still supplemented by peanut butter and jelly. 

Claudia continued to gain weight (Figure 6b) . During 
the next several months, we eliminated the peanut butter and 
jelly sandwiches one meal at a time. Much later, we had to 
put her on a diet and remove fattening desserts. We looked 
back at the early weight records and laughed. 

Building Nev; Behaviors I: Eye Contact 

In our concern over her rumination, we had given little 
thought to what V7e might teach Claudia. Several days had 
passed since we had begun rumination intervention and her 
trainers now had little to do but watch her. We did not 
dare return her unattended to the cottage day room for fear 
the rumination v/culd regain its previous rate. Claudia 
possessed a limdted behavioral repertoire and by reducing 
the rumination we had left her with almost nothing. Where 
to start building? 

"Attention span" was a logical prerequisite for training. 
Eye contact with the trainer was widely regarded as the first 
step in establishing visual attending behavior (Kozloff, 19 73; 
Foxx, 1977). In addition, it seemed that recognizing one's 
name was a necessary, basic skill, one that Claudia did not 
possess. We had never seen her respond to her name or to 
anyone's voice. Only loud noises and the sound of the cottage 
door and rolling food cart seemed to attract her attention. 



50 



We resolved to teach her to look at us when we called her 
name . 

To ascertain that she did not, in fact, knov7 her name, 
we began with a baseline procedure while she sat in her 
relaxation chair before meals. When Marsha was sure that 
Claudia was not looking at her, she would say, "Claudia, 
look at me" and record whether Claudia's eyes met her own 
within five seconds. Marsha continued in this manner for 
five weeks, about two minutes per session, and obtained 
relative frequencies of looking and not looking. During the 
first three weeks, Claudia rarely responded. Over the next 
two v/eeks, she began to make eye contact more frequently, 
but during only one session did she respond appropriately 
more often than not (Figure 7, phase A). 

We reasoned that if we continued in this way, Claudia 
might eventually learn to respond consistently to Marsha's 
voice. However, we wished to teach her more rapidly. We 
required Claudia to earn part of her meal by making eye 
contact. The procedure was similar to the previous one, 
except that it occurred during the first part of the meal. 
Marsha timed and counted the eye contacts, giving Claudia 
a spoonful of food on a continuous (CRF) schedule, one 
spoonful for each success. After Claudia had earned twenty 
spoonfuls, Marsha fed her the remainder of the meal. We had 
observed previously that Claudia's eyes invariably follov/ed 
the spoon during feeding. Vie used this finding to institute 
a "fading" procedure (e.g., Whaley & Malott, 1968; Bassinger 
et al. , 19 71) : Marsha began the training with the spoon 



51 




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directly in front of her eyes and over the next two and a 
half v^eeks gradually lowered it to plate level ("faded out" 
the spoon) while maintaining eye contact (Figure 7, phases 3, 
C) . After four and a half weeks the behavior was stable, but 
how long it had taken to teach such a simple response! Hank, 
my graduate advisor, was visiting one afternoon when Claudia 
was massing more responses than usual. I told him that I 
knew retardation training would be slow and painstaking, 
but until now I hadn't understood the definition of "slow." 
It was only the beginning. 

We had achieved some measure of control over the eye 
contact at mealtimes, and extending this skill to other 
situations seemed imperative. We must continue to use food 
to reinforce the behavior, that much was clear, but extra 
feeding between meals might increase the nomination. We 
opted for small bits of food, marshmallows and raisins, and 
conducted the session about an hour before meals. The effect 
was immediate. We lost our hard-won gains (Figure 7, phase D) 
Was it the change in session time, or was it the m.arshmallows 
and raisins? l-Jhen she discovered Claudia could chew, Susan 
had observed that Claudia would eat almost anything but was 
more excited by her meals than by the snacks. We replaced 
the marshmallows and raisins with small spoonfuls of blend 
and regained control of the eye contact (Figure 7, phase E) . 
We had lost control of the eye contact for a week, but our 
data were instructive: Candy has been widely used as a 
reinforcer, but our chart indicated that it would not 



53 

reinforce Claudia' s. hehayior. It v?as nice to know that she 
preferred nutritious substances to junk food, a finding 
that maintained throughout her training. 

V7e varied position and distance of the trainer relative 
to Claudia, and began rewarding the eye contact with blend 
on a variable ratio (VR) 2 schedule, about one spoonful for 
each two appropriate responses (Figure 7, phases F, G) . At 
the end of the project, Claudia always raised her eyes when 
we asked her to look at us. 

But we had failed in several respects. First, we did 
not teach "eye contact" with emphasis upon "contact." It was 
clear that Claudia was not looking at us. Rather, she had 
developed a cute, stereotyped response, eyes raised to about 
the level of our eyes, gaze fixed, mouth slightly open to 
receive the food, head cocked to one side. The fixed gaze, 
sometimes a shade above or below our eyes, let us know that 
she was not really looking at us. Second, she had not 
learned her name, nor did she respond to our voices except 
in a training situation, with spoon present. We could have 
continued the project, gradually increasing the ratio of 
responses to food, but to what avail? We couldn't modify 
the stereotyped responses. 

We gained much from this project, though. We had built 
a behavior, even if not exactly the one we had intended, 
where there was none before. Claudia could learn new skills. 
We also learned that "attention," or at least attention as we 
viewed it, was not a necessary first step in training. Her 



54 



progress in other areas without it would subsequently confirm 
that fact. She did begin to respond to her name and to really 
look at us, much later, as a by-product of the thousands of 
hours v;e worked with her. The "basic skills" turned out to 
be complex achievements. 

Claudia has never lost this first response she learned. 
Over the following two years the response would appear again, 
when we were trying to teach her new skills and having trouble, 
She would frequently raise her eyes and assume her old ex- 
pression, as if following the rule, "when all else fails, 
try eye contact." That facial expression became dear to us. 

Building New Behaviors II: Playing Catch 

After meals, Claudia's trainers generally gave her a 
soccer or large plastic ball to bounce while they monitored 
the rumination. She entertained herself this way for hours. 
When her trainer brought out the ball immediately after the 
meal, she grew excited. If the trainer bounced the ball 
before giving it to her, she frequently bounced in her seat 
V7hile watching. But once she was given the ball, she rarely 
returned it. 

We saw here an opportunity to interact with Claudia 
in a purely social manner. Teaching her to play catch might 
also give her a skill she could use on the cottage with other 
clients. And it was our first opportunity to play v/ith this 
girl who knew us only because we fed her and scolded her 
when she ruminated. 



55 



Her trainers tossed her the ball from about four feet 
av7ay , clapping their hands and telling her to throw it. If 
she threw or bounced it back;, the trainers counted a correct 
response. If she threw the ball in the wrong direction or 
failed to throw it at all within ten seconds, the trainer 
retrieved it and tried again, counting an inappropriate 
response. When we started, she returned the ball to us about 
half the time. In only four weeks, we all but eliminated the 
correct responses (Figure 8, phase A). Most of the time she 
threw it in the wrong direction, frequently over her shoulder. 
Perhaps she was responding to terminate the game or to watch 
us chase the ball. Either way, this was not our idea of a 
good time. 

We reviewed the situation and made note of the following: 
First, we were sure that playing with the ball was a rein- 
forcer. Before we had begun the catch program, Claudia 
reliably grew excited upon presentation of the ball and 
quickly retrieved it if it rolled away from her. She played 
with it for seemingly endless periods of time; this was a 
high-rate behavior and therefore a potential reinforcer 
(Premack, 1965). Second, we recalled the well-established 
findings that satiation decreases the effectiveness of rein- 
forcers and deprivation increases reinforcers' effectiveness. 
Prior to our interaction with Claudia, she rarely had access 
to balls; she now had access to them for several hours per 
day in addition to the catch-program time. We might well be 
observing the effect of satiation. If so, we would do well 



56 



to create instead a state of deprivation by limiting her 
access to the ball. Finally, we analyzed the consequences we 
had arranged for the game of catch. When Claudia responded 
correctly by throwing the ball to us, we threw it back, 
continuing her access to the reinforcer. Hov^ever , inappro- 
priate throv/s resulted in almost the same consequence — we 
retrieved the ball and threw it to her again. A widely-used, 
highly successful method of reducing inappropriate behavior 
is "timeout," the brief withdrawal of a reinforcer contingent 
upon the undesired response. Perhaps such an arrangement — 
briefly limiting access to the ball after incorrect throws — 
would be an effective consequence. 

Based on our analysis, we changed the rules of the game 
so that she would play our way or not at all. We only gave 
her access to the ball during sessions. If she threw it in 
the wrong direction we stopped the game for two minutes (the 
stopwatch did not run during this time) . If she threw it in 
the wrong direction twice in succession, we terminated the 
game and did not play again until after her next meal. 

It was hard to enforce the new rules. We were growing 
fond of Claudia and playing with the ball was the only thing, 
except eating and going out with Julia, she liked to do. We 
did not like to take away the ball, but we were determined 
to teach her to play with others. Most of her fellow clients 
seemed to enjoy our attention, and we were spending more 
tim.e with Claudia. Besides, we didn't enjoy chasing the ball 
around the cottage. 



57 



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We '.hung on and slowly, imperceptibly, she began to play 
(Figure 8, phase B) . After eleven weeks, we terminated the 
procedure, or rather she terminated it. She would throw the 
ball as long as anyone was willing to play with her and she 
wore out trainer after trainer. We gave her free access to 
the ball again and the choice was hers. If she wanted to 
play, we'd play, but we were grateful for the rest when she 
bounced the ball by herself. 

Trainers who have resigned return to visit the program 
and usually play catch with Claudia. It's easy to buy her 
a present she will appreciate, and she owns a truly impressive 
assortm.ent of balls. 

By-Products of the Early Training 

Claudia's success in her new programs bolstered our 
confidence. We had begun the eye contact and ball-toss 
sessions simultaneously, within a week after starting the 
rumination intervention. The rumination rate remained low 
v/hile Claudia acquired her new skills. Most of our staff 
worked with Claudia at one time or another, and we were all 
excited and proud. 

But in early spring, the staff had some bad news for 
Marsha, Georgianne, and me, the people responsible for her 
training. "Your baby," they told us, "is spoiled rotten." 
We couldn't deny it. Before training began, Claudia had 
lain passively on the day room floor, growing excited only 
when Julia or the food cart arrived. Now there were occasional 
tantrums if her trainer arrived late for her meals. She would 



59 



cry and rock forward, sometiines banging her head on the floor. 
We were not worried about these tantrums, they seldom hap- 
pened and the head banging occurred only rarely. Usually, 
she merely rocked, her forehead stopping inches from the 
floor. Occasionally she hit it and looked at us, commencing 
to cry. At least she knows us, we thought. The tantrums 
did not become a problem. We generally arrived before the 
food, and if a tantrum was in progress we did not begin her 
session until she was quiet. 

A more pressing problem was after-meal tantrums. We 
were still keeping her in the relaxation chair for a brief 
period following each meal, the crucial time for rumination. 
We were reducing this chair time, but evidently not fast 
enough for Claudia. She began screaming and crying, jerking 
around in the chair. We did not want to take her out once 
she started crying and risk teaching her to misbehave. 
Neither could we use an "extinction" method, that is, simply 
ignore Claudia until the tantrum ceased. Her behavior was 
more violent in the chair than during premeal tantrums and 
we were afraid that if we ignored her, she'd hurt herself 
while destroying the chair. 

We simply could not let the tantrums begin. I took 
advantage of the chair's mobility, rolling it up and down 
the hall soon after she finished her m.eal. I could keep a 
close eye on her in case of rumination and she seemed to 
enjoy the ride; she gave me one of her rare smiles. I pulled 
a little faster, she smiled more. The weather was turning 



60 



pleasant, so I rolled her out of the cottage and we v^ent 
tearing up and dovv-n the sidewalk. She laughed long and hard, 
and won our hearts. 

Basic Self-Feeding Skills 

By early April we had a name for our program, STARS 
(for Start Training Appropriate Responses to Stimuli) , a new 
training building, and a budget. It was spring and a time 
for change . 

Marsha, George, and I grew more ambitious with Claudia's 
training. She had shown herself capable of at least simple 
skills, given time, patience, and careful monitoring by 
those who worked with her. Virtually everything had to be 
done for her and we wished to help her acquire more inde- 
pendence. The two areas that appeared to offer the best 
beginning were feeding and ambulation. Although her move- 
ments were jerky, Claudia v;as not spastic, so independent 
feeding did not seem an unreasonable goal. The triple 
arthrodesis operation several years earlier had left her 
physically capable of walking. We tackled both problems 
at once. 

Learning to Scoop 

Teaching Claudia to feed herself was perhaps the most 
initially promising and eventually frustrating project we 
attempted. She acquired the basic skill, independent 
scooping, more rapidly than anything else we taught her. 
Polishing the basic behavior and adding related skills was 



61 



an incredibly slow process and we met with failure more 
than once. 

We began, of course, in the relaxation chair at meal- 
time. The chair was as ideal for teaching feeding as it was 
for monitoring the rumination. She sat straight and the 
clip-on tray was at a comfortable height. As much as she 
loved to eat, we knew she would be highly motivated to learn 
this new skill. 

She had no trouble holding a teaspoon loosely in her 
fist, but we were unable to induce her to hold it as one 
usually does, between the index and third fingers with thumb 
on top. However, we had observed many clients feeding them- 
selves using a fist-grip. It was more awkward than a normal 
grip but it seemed to get the job done. We considered our- 
selves to be lucky that Claudia held the spoon at all without 
prior training and we accepted the fist-grip. Her grasp was 
not strong, however; so we began the program with a built-up 
spoon, a commercially available product that has been suc- 
cessfully used to teach feeding skills to the profoundly 
retarded (Miller, Patton, and Henton, 1971) . The handle of 
the spoon was a plastic cylinder three-quarters inch in 
diameter. This Claudia held firmly enough. 

The procedure was simple. For the first few trials, , 
Marsha wrapped her hand around Claudia's and guided her 
through the entire motion, lowering the spoon, loading it 
with food, and raising it to her mouth. Marsha felt little 
resistance from Claudia's arm; the movement was smooth and 



62 



natural. Marsha next released her hand and Claudia, with 
soroe difficulty, successfully loaded the spoon and fed 
herself. Claudia was awkward but persistent and Marsha did 
not intervene on a given scoop until it became clear that 
Claudia would not succeed on her own. When such was the case, 
Marsha took Claudia's hand and finished the scoop with her. 
Claudia was free to try alone on the next scoop. The first 
day, Claudia scooped without assistance in one of every four 
attempts. In little more than _ a week she was scooping entirely 
independently. We allowed her to continue in this manner for 
several more weeks to gain proficiency. On the first day of 
training she had scooped independently at the rate of once 
per two minutes. Her speed rapidly increased to about eight 
scoops per minute (Figure 9 , phase A) . 

Once again, Claudia had come through for us. For 
seventeen and a half years she had been fed and within a few 
weeks was able to scoop on her own. It was so easy. We 
planned to put on the finishing touches, to teach her to 
use a regular spoon and to eat more neatly so that we could 
remove her bib. We were to be surprised and disappointed. 

Fine Details of Scooping 

Although she was scooping rapidly and without assistance, 
Claudia was making a mess. She had added a new component 
to the scooping movement, rolling her wrist as she lifted 
the spoon to her mouth, taking it in upside down. Much of 
her diet v/as soft and sticky and adhered to the spoon, but 
the remainder landed on her bib, the tray, and the floor. 



63 




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We had not intervened as the behavior developed since we 
did not wish to interfere with her independent scoops. 

We concentrated on the wrist rolling. Her grasp was 
firmer nov7, and we replaced the built-up spoon with a regular 
teaspoon, the handle of which we covered with friction tape 
to prevent slipping. We temporarily discontinued monitoring 
the unassisted scoops and began assisting her again, cor- 
recting position of spoon and wrist. We were not successful; 
we were unable to decrease the frequency of assistance 
(Figure 9, phase B) . We also had to intervene in other ways. 
She was taking larger and larger spoonfuls. At one point, 
she lifted her entire portion of mashed potatoes and at- 
tempted to get them all in her mouth. She was as likely to 
scoop the food from her bib or the tray as she was from the 
plate. We began blocking the large and off-plate scoops, 
each block accompanied by an assist to initiate a correct 
scoop. We were unsuccessful again (phase C) . At least, we 
consoled one another, she never attempted to use her fingers, 
even when struggling to scoop a small morsel from the corner 
of the plate. 

We decided to begin afresh, to build a new scooping 
movement. For several weeks we held her wrist on every scoop, 
guiding her entirely through the motion. Then we gradually 
allowed her to scoop independently, increasing the frequency 
of unassisted scoops until they accounted for 75% of the 
total (phase D) . 



68 

The frequency of large scoops was decreased and the 
wrist-rolling was gone. Gone also v;as the tape on the spoon, 
worn off by repeated washing. Her grip was solid so we did 
not replace the tape. But now there was a new problem. She 
had begun scooping backhanded, shoving most of the food off 
the rear edge of the plate. We repeated our strategy, be- 
ginning with complete assistance and then allowing increasing 
numbers of independent scoops (phase E) . Before she had 
even achieved one independent scoop per minute, her backhand 
returned. Again we assisted her entirely, then relaxed the 
assistance, and again she back-scooped (phase F) , 

We did not know what else to do. We considered several 
strategies and rejected them. Many more ideas, of course, 
present themselves in hindsight. But we coped with the 
problem in our usual manner. We returned to complete physical 
assistance, this time for several months (Figure 9, phase G) . 

Many changes occurred during this period. Claudia began 
eating at the campus cafeteria as a result of her progress in 
other training sessions. The change in scenery did not help; 
occasional probes revealed that the backhanded scooping would 
reappear if given the chance. None of us could think of a 
way to m.odify the behavior. 

In January, 1977, more out of frustration and discourage- 
ment than out of any change we observed in Claudia's behavior, 
we changed the procedure. We allowed her to scoop indepen- 
dently, blocking and re-directing any attempted backhand 
scoops. She immediately regained her original independent 



69 



scooping rate of eight per minute. We had to assist her just 
over once per minute and elected to wait and see what hap- 
pened (Figure 9, phase H) . Over the next seven months, the 
rate of assistance decreased to about once in five minutes, 
or several assists per meal. 

We had, I suppose, succeeded. But the behavior change 
was small in relation to our expectations. We nevertheless 
continued to work on her feeding skills, meeting with success 
in some attempts and failure in others. Had Claudia not 
shown such remarkable progress in other areas, we would have 
been thoroughly discouraged. 

Learning to Walk 

While Claudia's progress in her feeding programs was 
slow and often discouraging, helping her acquire ambulation 
skills rewarded us often. Progress was rapid at tim>es and 
slow at others. The training frequently bogged down and was 
then revitalized by a sudden breakthrough. We had to face 
limits in some areas while in others she continued to grow. 
Teaching her to walk provided both the most challenging and 
gratifying experiences we had with her. 

We had been considering teaching Claudia to walk from 
the time v/e began working with her rumination. She had 
undergone the operation to repair her feet, giving her the 
physical capability to walk. Examining the conditions under 
v^hich she ruminated, I had discovered that she would walk 
short distances if I held her hand tightly. However, the 



70 



rumination caused us to delay the start of formal walking. 
We wanted first to bring the rumination under control and 
effect a weight gain, as we were afraid that her pathetic 
legs could not withstand any strain. While we waited, we 
began several preliminary programs to assess her current 
capabilities and to exercise her legs. 

Preparatory Programs 

The day after rumination intervention began, we started 
walking Claudia for a minute or two at a time, several times 
per day. Her trainers held her hands tightly but made no 
effort to force her to walk. She walked at a rate of fifty 
to eighty steps per minute, sitting down every fifteen to 
twenty seconds. Her steps were small, each covering about 
eight inches. They were not uncertain, clearly steps and 
not shuffles, but they were jerky and she swayed from side 
to side. This peculiar gait may have been due to the fact 
that she never developed hip rotation. The swaying motion, 
while greatly reduced, has never disappeared and one can 
always spot Claudia walking, even at a distance. 

For additional exercise we had her push an empty wheel- 
chair. Her trainers walked behind her, keeping her hands 
firmly on the grips. She walked slightly faster with the 
wheelchair, between ninety and one hundred steps per minute. 
However, we abandoned the program within two weeks as keeping 
her hands on the chair was a problem and the trainers had 
trouble positioning themselves, leaning over her to maintain 
contact with her hands. 



71 



Walking provided only several minutes of exercise each 
day and we did not feel that this was adequate. Although it 
was winter, it was frequently warm enough to go out during 
the afternoon, so we tried our luck with a tricycle. A 
trike would exercise her legs for about ten minutes at a time 
without straining her. Not her, perhaps, but it certainly 
strained us. Claudia would not keep her feet on the pedals. 
We tried built-up pedals, straps, and pedal stirrups, but 
with a wiggle or two of her feet she undid our best efforts. 
Several shoe laces tied end to end finally served the purpose. 
Enough loops and knots and twists and turns, and her feet 
remained firmly planted on the pedals. At first it took two 
of us, one to balance her on the seat and one to perform the 
elaborate tying-on ritual. When she became accustomed to 
the trike, she helped by sitting still and only one trainer 
was necessary. 

VJith her obviously limited tricycling experience, we 
were not surprised to find that Claudia did not pedal. For 
three weeks we pushed her. The rotating pedals stretched 
and flexed her legs, giving them at least some exercise. In 
the middle of March, we noticed that we didii't have to push 
as often — Claudia was doing some of the work too. We counted 
assists to move or steer, initially providing assistance almost 
six times per miinute (Figure 10, phase A). Three weeks later, 
when we began her form.al walking programs, we v/ere still 
assisting her at this rate, but there had been several days 
during which substantially fewer assists V7ere necessary. 



72 




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73 



The tricycle h,ad served its original purpose in that it had 
given Claudia exercise preparatory to walking. But these 
first signs of success on the trike encouraged us to continue 
the program as an added form of recreation. We maintained 
the program only sporadically, but Claudia slowly improved. 
At the end of July, we happily dispensed with the shoelaces, 
and she kept her feet on the pedals (Figure 10, phase B) . 
A year and a half later, Claudia graduated to a bicycle 
with training wheels. She pedaled with nowhere near the 
proficiency required to eliminate the training wheels, but 
we V7ere satisfied. We had set out to give her exercise, and 
she had learned a new recreational skill in the process. 

The First Independent Steps 

We began formal walking sessions in early April on the 
same day we began teaching Claudia to feed herself, and 
precisely two months after we began rumination intervention. 
She weighed sixty-six pounds, seventeen pounds more than when 
we met her, and we had observed no problems during her pre- 
vious exercise programs. She seemed ready to walk alone. 

We took her into the long hall that connects the girls' 
and boys' wings and let her sit on the floor, I sat beside 
her and showed her a cup with several sips of fruit juice in 
it. She became excited as she always did, rubbing her eyes 
and nose. I stood, walked back about eight feet, and stopped, 
always keeping the cup in plain view. She watched intently. 
From behind, Georgianne placed her hands in Claudia's armpits, 



74 



lifted Claudia to a standing position, and walked her forward. 
About four feet in front of me, Georgianne let go. Claudia 
walked — more precisely, staggered — her first independent 
steps to my arms and her juice. We repeated the procedure 
and again she walked the last few steps alone. We were 
jubilant. 

Then, caught up in the excitement of the moment, I erred 
badly. i wanted to see how far she would walk by herself. 
On the next attempt, I began walking backwards as she ap- 
proached me, keeping about one and a half feet between us. 
She followed me for perhaps twenty feet, stopped abruptly, 
and sat down. I had pushed her too far. The sudden, drastic 
increase in the number of steps required for a sip of juice 
had probably extinguished the walking: Claudia had responded 
appropriately, I had failed to reinforce the behavior, and 
the walking disappeared. In such situations, merely requiring 
less work for each reinforcer is usually sufficient to re- 
instate the behavior (Reynolds, 19 6 8; Krumboltz & Krumboltz, 
1972) . 

We therefore tried again, only this time I had no inten- 
tion of moving. A few independent steps would have satisfied 
me. None were forthcoming. As soon as Georgianne started to 
remove her hands from the armpits Claudia went down. Nine 
m.ore attempts produced the same result. I was furious with 
myself. Weeks of preparation and planning, the sight of 
Claudia walking alone, and I had apparently negated all of 
it. 



75 



This was also more than a little curious. Claudia had 
taken weeks to learn to make eye contact, and was not at the 
time even close to reliably throwing her ball back to her 
trainers. Yet I had pushed the walking just once and it 
disappeared. How could one who learned so slowly suddenly 
learn so fast? How could Claudia be so insensitive to some 
things in her environment and so sensitive to others? And 
why did her sensitivities seem to work against us? I did 
not know the answers then, nor do I now. 

We did know, however, that the last time she had walked 
I was holding a cup of juice and was moving away from her. 
We tried again, but this time I did not hold the cup. We 
moved Claudia into the kitchen, I showed her the cup, placed 
it at the edge of a counter, and moved away. Georgianne 
lifted her as before, walked her tov;ard the counter, and let 
go. Claudia covered the remaining three feet on her own and 
(with Georgianne 's help) collected her well-deserved juice. 

We continued in the kitchen for a week, ten to twenty 
trials per day. We recorded the number of independent steps 
per trial and gradually increased the distance we required 
Claudia to walk by herself (Figure 11, phase A). We ran out 
of room when she reached eight steps per trial and moved back 
into the hall. We set up two small tables and substituted 
spoonfuls of blend for the juice. Georgianne left Claudia 
sitting at one table and placed the spoon on the other table. 
She returned to Claudia and helped her up, but it was no 
longer necessary to start walking with her; Claudia was able 



76 









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77 



to begin each trial from a standing, stationary position. 
Claudia walked back and forth, receiving the blend and a 
brief rest at each table. We increased the distance day by 
day until she traversed the entire hall, seventy of her 
small steps (Figure 11, phase B) . 

At each end of the hall was a short passageway leading 
to the living wing doors. V7e moved the tables into these 
passageways, out of Claudia's sight. She was able to turn 
the corners and find her blend. During these sessions she 
never stopped and sat down before reaching the goal and her 
balance, while still not the best, improved. 

While we were conducting these formal walking sessions, 
we also encouraged Claudia's trainers to give her extra, 
non-food-rewarded practice. The practice consisted of "gradu- 
ated guidance" (Foxx & Azrin, 1973; Sundel & Sundel, 1975), 
having Claudia walk with as little assistance as possible. 
For example, after a meal, Claudia's trainer might walk her 
from the relaxation chair to the lounge, holding her wrists 
firmly at first, easing the pressure as she walked, and finally 
letting go. We counted her attempts to sit down during these 
short walks and discovered we were having no success (Figure 12) 
Although she attempted to sit dovm less frequently than she 
did before we began training, the rate showed no further 
decrease as training progressed. We also realized that we 
were possibly working against ourselves by requiring her to 
v/alk without assistance in some situations while helping her 
in others. 



78 



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79 



We abandoned the graduated guidance program and required 
her to walk short distances in the cottages by herself. 
When she sat down, which she did frequently, we helped her 
up but did not assist her in the walking. It was back- 
breaking work and occasionally took twenty minutes to cover 
the short distance from lobby to living wing. We didn't mind, 
for she was walking alone. 

Rumination Redux 

Unmonitored Rumination 

Although we had expanded Claudia's training into many 
areas, our primary concern remiained the rumination. We moni- 
tored its frequency constantly as we added new training 
programs and it did not increase. 

We calculated the rate based upon the amount of time 
Claudia spent with us, initially about ten hours per day. 
Several months into her training, I became curious to know 
how she fared when we were not present, from 7:00 p.m. until 
bedtime, about nine or ten o'clock. The cottage parents 
told m.e she was ruminating, though not nearly as often as 
she had previously. I stayed late one night to find out. 

As the other trainers left for the evening, I handed my 
stopwatch to Betty, one of the cottage parents. I instructed 
her to start the watch as soon as she heard me close and lock 
the door, and to turn it off the first time Claudia ruminated. 
She was then to bang on the plexiglass window in the door, 
signalling me to return. I left the living wing and had not 



so 



yet seated myself in the office when Betty signaled. I 
returned to the wing and read the stopwatch, seven seconds. 
I had the washbottle of lemon juice in my pocket but did 
not remove it. Claudia and I stared at one another for a 
short time. I did not say or do anything as she did not 
ruminate again. I reset the watch, gave it back to Betty, 
and exited. I only walked far enough to be clear of the 
plexiglass window, knowing that I ' d be wasting time to walk 
further. I was correct; the latency to ruminate was five 
seconds. This time, I had quite a bit to say to Claudia. It 
didn't bother me that she couldn't discriminate her own name, 
let alone the content of my lecture about behavior management 
skills. It seemed as good a way as any to pass the time 
and see if she would ruminate in my presence. She did not, 
of course, and fifteen minutes later, Betty and I tried again. 
Each of the next three trials registered less than 15 seconds 
latency. 

It is well-known that individuals in programs such as 
Claudia's-- programs designed to eliminate undesirable be- 
havior — quickly learn when it is and is not "safe" to emit 
the target behavior (Lovaas & Simmons, 1969; Rollings, Bau- 
meister, & Baumeister, 1977). Claudia's performance that 
night indicated that she had learned. I went home to ponder 
the problems of after-hours rumination. 

Several days af ter>7ard^ I stayed late again to v7ork in 
the office. It was not hard to avoid the living wing and a 
rediscovery of Claudia's unmcnitored rumination. However, I 



81 



did not stop working until after 10:00 p.m. and I couldn't 
resist looking in to see our kids, so noisy and unmanageable 
by day, sleeping peacefully. Some clients slept, others 
were awake but relaxed, and Claudia lay comfortably curled 
up, ruminating. 

1 considered the alternatives. We could not extend our 
training schedule, and Claudia was already receiving more of 
our time than was any other client. Neither did I want to 
ask the cottage parents to intervene in the rumination. Two 
of them were responsible for showering the girls and putting 
them to bed, and I couldn't expect them to monitor and inter- 
vene consistently. In addition, the Florida behavior manage- 
ment guidelines, while unclear on the point, seemed to forbid 
such intervention by untrained personnel. 

T therefore took no action and hoped for the best. The 
decision eventually proved correct. The nighttime ruminating 
gradually decreased, as verified by the cottage parents' 
reports and our periodic monitoring. 

Procedural Revision 

The first week in April, just before we began Claudia's 
walking program., I happened upon a fascinating occurrence in 
the boys' wing. One of the cottage parents was preparing to 
mop the floor after lunch when a client distracted her. As 
she tended to the boy, another client spied the open, unguarded 
closet. He rushed over, reached in, and removed an open bot- 
tle of detergent, which he began drinking with gusto. Several 
of us reached him simultaneously and grabbed the bottle 



82 



before he had consumed very much. No harm had been done and 
he laughed gleefully at our angry gestures and admonishments. 

Here was I, convinced that the sour, concentrated lemon 
juice was controlling Claudia's rumination. The detergent 
certainly couldn't taste much better, but I had just seen a 
client consume it with apparent relish. The client was known 
for his pranks and he invariably laughed at our scoldings; 
the attention we paid him quite likely overrode the taste of 
the detergent. Perhaps it was not the lemon juice but some 
other more powerful aspect of our procedure that controlled 
the ruminating. 

1 had a chance to find out the day we began Claudia's 
walking sessions. Georgianne was struggling with Claudia in 
the ill-fated assisted v/alking program. I approached with 
the wash bottle of lemon juice, held it up, and sweetly 
offered it to Claudia. The struggling ceased and she con- 
tinued walking; Georgianne did not let go, however, remember- 
ing our experience in the hall earlier that day. When Claudia 
reached me, I gently squeezed a squirt of the lemon juice into 
her mouth, caressed her hair, and told her what a good girl 
she was. She did not flinch or jerk away as she always did 
when we swooped down on her after a rumination. We sat her 
down and I induced her to make eye contact repeatedly in 
return for squirts of lemon juice delivered in this gentle 
m.anner. 

The results were not surprising. Researchers in the 
laboratory and in teaching situations have demonstrated that 



83 

the events usually used to decrease bahavioir rates can also — 
when programmed differently-- serve to reinforce behavior 
(Kelleher & Morse,' 1968; Morse & Kelleher, 1970; Plumrier, 
Baer, & LeBlanc, 1977; Solnick, Rincover, & Peterson, 1977). 

In hindsight, I realize that I could have been more 
thorough. For example, I could have replaced the lemon 
juice with fruit juice and continued with the wash bottle 
procedure, observing the effect upon rumination frequency. 
The simple demonstration with the lemon juice, however, con- 
vinced me to alter our intervention strategy. I reasoned 
that the manner of delivery was the relevant aspect of the 
procedure, an excited, rapid jab with the wash bottle versus 
a gentle slow squeeze. The amount and kind of juice were 
identical but the results markedly different. 

We disposed of the wash bottle. With the new training 
programs it was a nuisance to carry and besides, it leaked. 
We used our hands instead, holding her cheeks between thumb 
and third finger, pointing at her tongue with the index 
finger. We administered this consequence as we had the lemon 
juice, quickly and sternly. 

For several days, the rumination frequency rose slightly 
but remained v/ell within the range displayed since training 
began (Figure 13, phase I). It returned thereafter to its 
usual low level and we continued without the lemon juice. 

Reversal and Return to Intervention 

By June, there was still no change in the rumination rate, 
and we thought that we had decreased it as much as possible. 



84 




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88 



It therefore seemed a likely time to abandon the cheek-hold 
procedure. We agreed to ignore the rumination and continue 
all other aspects of Claudia's training. Not wishing to 
inadvertently reinforce the rumination, we planned to dis- 
continue for several minutes any session in progress when a 
rumination occurred. 

The ruminating did not increase during the first two 
days (Figure 13, phase J). On the third day, however, 
Claudia averaged one rumination per twenty minutes, a rate 
equalled or exceeded only in the first two days of the ori- 
ginal intervention. In the following week, the rate dropped, 
climbed, dropped, and climbed again. Overall, it was slightly 
but noticeably higher than during intervention. We knew 
that this outcome was likely. We had not decreased the ru- 
mination rate to zero and Claudia had therefore immediately 
contacted the procedural change — she ruminated without con- 
sequence in the presence of her trainers. We were not alarmed, 
however. Research had shown that response-reduction proce- 
dures could be eliminated, then reinstated with no loss in 
effectiveness (Azrin & Holz, 1966). While we did not worry, 
neither were we willing to wait. We well remembered Claudia's 
appearance four months earlier. We reins tituted the cheek- 
hold procedure and left it permianently in place (phase K) . 

The rumination frequency gradually declined. In Novem- 
ber, 1977, eleven months after we had resumed holding Claudia's 
cheeks', there w^ere more days during which we saw no rumination 
than there were days on which rumination occurred. By January, 
19 78, several weeks would pass between ruminations. 



89 



In the summer of 1978, milk was briefly reinstituted in 
Claudia's diet; it had been removed at the same tim.e as v/as 
Sustacal. The rumination frequency rose slightly but per- 
ceptibly (phase L) ; so milk was permanently removed from her 
diet (phase M) . 

As the likelihood of rumination decreased, we gradually 
reduced the amount of Claudia's training time. We were even- 
tually able to safely return her to the cottage living wing 
within one to one and a half hours after each meal. Whenever 
we felt she was ready for a decrease in training time, we 
spent several v/eeks monitoring her in the living wing. We 
would return her to the day room and leave, then quietly 
enter through a side door and station ourselves out of sight. 
We observed no rumination during these periods. 

Although the ruminations were few and far between, we 
never abandoned the cheek-hold procedure. There was simiply 
no reason to do so. The procedure was all but unused any^^ay, 
since there v/ere so few ruminations. However, when a rumina- 
tion did occur, we felt it best to deliver the consequences 
to keep the rate as near zero as possible. 

When the rumination had almost vanished, hiring new 
trainers presented a problem. Our original trainers and those 
hired while Claudia was still ruminating daily understood the 
importance of the rumination procedure and had many opportuni- 
ties to observe the response. Trainers hired later, however, 
operated under a handicap. They rarely saw Claudia ruminate 
and thus did not know what they were looking for. They also 



90 



had difficulty understanding why members of the original 
staff became upset if a rumination occurred and the conse- 
quences were not immediately delivered. How could they 
understand? They had not known the other Claudia. 

In the spring of 19 76, we took our clients to a picnic 
at some lakeside property owned by Sunland. I brought along 
a camera to record this first of many outings we enjoyed 
over the next several years. When the pictures were developed 
we realized that we had not been keeping the most important 
records of all. These children had changed. Photographic 
documentation immediately became an integral component of 
the STARS Program. For som.e of the clients, like Claudia, . 
the documentation came too late. I recorded on film many of 
her accomplishments in motor and self-care skills. But 
missing was the most obvious change of all, that caused by 
the reduction in rumination. 

Our new trainers did not know Claudia as she was before 
and we had nothing to show them save a blurry snapshot from 
her cottage records. Our charts precisely documented Claudia's 
progress but they did not reflect her transformation from a 
pale, wasted figure on the cottage floor to a healthy girl 
capable of learning many new things. 

Advanced Ambulation Skills 

Walking Outdoors 

When Claudia was able to walk the length of the cottage 
hall, we eagerly moved the session outdoors. A long, straight 



91 



sidewalk runs from the street to Lilac's, front porch. It was 
ideal for increasing the distance Claudia was required to 
walk on each trial. The sidewalk is level and was therefore 
a good place to teach her to walk on surfaces other than 
smooth tile. There were no bumps and slopes that her poor 
balance could not accomodate. 

We set up two small vinyl chairs not quite thirty feet 
apart. This was less distance than we required Claudia to 
walk indoors but seemed adequate in view of the radical 
change in environment. We used a procedure similar to that 
employed for indoor walking. We sat Claudia in one chair 
and put a spoonful of blend or her regular meal in the 
opposite chair, helped her to a standing position, and let 
her go. When she arrived at the other chair we simultaneously 
gave her the food and helped her sit down. After a brief 
rest, she returned to the first chair in the same manner. She 
made ten to fifteen one-way trips prior to each meal. 

Claudia performed well for the first three days, then 
caught a twenty- four hour virus. When she regained her 
health, there was trouble. There was a crack in the sidev/alk 
about twenty-three feet from the front porch and when she 
reached the crack she sat down. Although the crack was more 
prominent than the small spaces between successive blocks, 
the sidewalk had not buckled and thus presented no physical 
barrier. We stood her up and held her V7rists as she crossed, 
walking her back and forth over it. Still she failed to 
cross the crack without assistance; so we moved the other 



92 



chair directly over it. Over several days we inched the chair 
back until the crack was directly under its front legs. We 
continued backing up the chair and the problem did not re- 
appear, even when Claudia had to cross the crack entirely 
to reach the opposite chair. We did, however, sporadically 
see similar behavior throughout her training. A crack, a 
parking stripe, a change in sidewalk color, and the like 
occasionally stopped her. A gentle push and she crossed; 
stopping did not interfere significantly with her progress. 

Having solved the crack dilemma, we moved the chairs 
apart at the rate of about one foot per week until we reached 
forty-seven feet, the full length of the sidewalk. Unlike 
her behavior while walking indoors, she did stop and sit 
down occaionally before reaching the chair. In these cir- 
cumstances, we stood her up, made her walk back to the chair 
from which she had departed and start again. This did not 
occur often and was of no major concern. 

During the between-chairs walking sessions, her step 
size increased to about one foot per step and her rate was 
stable at just over a hundred steps per minute. The rate 
remained constant — on level surfaces — throughout her train- 
ing, while her step size increased to one foot, five inches. 

Auxiliary Skills I: Into and Out of Chairs 

Soon after we began the betv/een-chairs v;^alking program, 
it occurred to us that teaching her to walk was not sufficient. 
If Claudia was to learn to walk independently, she would need 
a variety of auxiliary skills, such as standing up, sitting 



93 



down, climbing stairs, and walking over rough terrain. We 
therefore designed a series of programs mostly composed of 
the popular technique of "shaping" and "fading," guided 
always by Claudia's charted performance. We built each 
behavior slowly and insured that Claudia could employ the 
skill in a variety of settings. 

If we expected her to use her new walking skill, we had 
to teach her to initiate it. Consequently, our first new 
programs were designed to teach her to get into and out of 
chairs and to get up from the floor, where she spent a 
considerable amount of time. 

We had been giving Claudia as little help as possible 
getting out of her chair during the early stages of the 
be tv/e en- chairs walking program, and she was almost able to 
accomplish the task on her own. Once out of the chair, 
however, she had to walk quite a distance for her food and 
we reasoned that if we placed the food closer to the chair 
she might stand up without assistance. At one end of the 
cottage hall stood a clothes dryer and an ice machine. We 
placed her chair one and a half feet in front of the ice 
machine and set the spoon on top of it. Arms outstretched, 
she rocked forward several times, finally gaining enough 
momentum to stand and brace herself against the ice machine, 
whereupon she received the food. We continued the procedure 
for two weeks, timing each entire session of about five 
minutes and counting the number of times she successfully 
got to her feet (Figure 14, phase A). She quickly reached a 



94 



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rate of about five per minute, the maximum she could obtain 
accounting for the time spent receiving and chewing the food. 
We subsequently moved the chair further from the ice machine, 
and when we ran out of room in the hall, we' moved the ses- 
sion to the back porch and placed the spoon on the relaxa- 
tion chair (phases B through F). On the porch, she was 
walking fourteen feet from chair to spoon. 

We increased the distance in this fashion for two 
reasons. First, she was initially barely able to rock her- 
self out of the chair, and having gained her feet, her 
balance was not good. During the first phase of training she 
could catch herself on the ice machine. When her balance 
improved, we moved the chair yet further, and standing and 
walking became a smoothly executed movement. 

The second reason for moving the chair back was to 
insure that she could execute the standing up motion without 
immediate reinforcement. Her progress was reflected in the 
between-chairs walking program, in which her trainers no 
longer had to help her out of the chair. Faced with the ever 
increasing distance between the chairs, she occasionally 
balked. However, a few tugs on her sleeve sufficed to get 
her started. 

Having taught Claudia to get out of the chair without 
assistance, we approached the problem of getting her into the 
chair. We began on the back porch., with Claudia in the chair 
facing the guardrail, about one and a half feet away from it. 
We had her stand up and grasp the rail, then lower herself 



96 



into the chair v/hile letting go (phase G) . We counted and 
timed each behavior as before. This was fine, except that we 
had merely succeeded in replacing ourselves with the rail; 
Claudia still needed assistance in getting into the chair. 
We planned to move the chair back gradually and eliminate the 
rail, as we had eliminated the ice machine when teaching her 
to get out of the chair. When we considered the motion re- 
quired to seat oneself, we realized the folly of our scheme. 
Unless one is very tired or otherwise indisposed, one gener- 
ally approaches a chair from the front and spins about, 
simultaneously lowering oneself onto the seat. Such a com- 
plex response, or even a chain of simpler responses with the 
turning and lowering trained separately, was beyond either 
Claudia's capability or our teaching skills. 

We elected instead to teach Claudia to use the back of 
the chair for support. We moved the program back into the 
hall. We placed Claudia in the chair, seated parallel to 
the wall, about one foot away from it. The trainer assisted 
her to stand up and put one hand on the wall, placing the 
other on the chair's backrest. From there, she could lower 
herself into it (phase H) . When she was able to execute the 
motion without her trainer's help, we moved the chair three 
feet further from the wall so that Claudia had to walk to it 
and seat herself using the backrest and the seat of the chair 
for support (phase I) . ' This manner of sitting down proved 
successful. Without specific training she applied the process 
to any chairs, couches, and benches she encountered. 



97 



In the process of teaching her to sit down, however, 
we learned another lesson of profound retardation: conduct 
each training session with complete regard for all other 
training in progress. In our eagerness and impatience to 
teach Claudia to get into the chair v/e had assisted her in 
getting out. We succeeded in speeding up the into-chair 
training sessions, but she would not get up on her ov/n during 
the between-chairs walking program. We temporarily had to 
reinstate the out-of-chair procedure. During the retraining, 
we patiently allowed her to seat herself. 

Auxiliary Skills II: Standing Up from the Floor 

There were only a few chairs in the cottage day room, 
and at our insistence, a bench had been installed. These 
were usually occupied by the higher-level clients, leaving 
the floor to the lower-functioning and non-ambulatory clients, 
Since we usually found Claudia on the floor, it was impera- 
tive to teach her to get up and start walking on her own. 
We began by offering her our hands. We did not pull 
her; we merely extended our hands and let her pull up, where- 
upon she received the spoonful of food without which we could 
induce her to do absolutely nothing. We then reseated her 
and repeated the process for about two minutes. She pulled 
herself up in this fashion slightly less than twice per 
minute (Figure 15, phase A), and we wondered if we might have 
more success by substituting inanimate objects for ourselves. 
We used the dryer in the hall, placing Claudia directly 
in front of it and the spoon on top of it. Rocking forward. 



98 




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99 



she placed her hands, on top of the dryer and pulled herself 
to a standing position without assistance from the trainer. 
We timed the entire session as we had before, counting the 
number of times she stood up. She initially stood up twice 
per minute and increased the frequency to seven per minute in 
three and a half weeks (phase B) . 

Although Claudia proficiently used the dryer to stand up, 
we wanted to insure that she could sim.ilarly use any available 
object. A behavior learned in one setting will frequently 
fail to occur in other settings without explicit programming 
(Rekers & Lovaas, 19 74; Stokes, Baer, & Jackson, 19 74; Koegal 
& Rincover, 1977) . We therefore conducted the session in a 
variety of locations, moving from the dryer to the ice machine, 
clothes chest, and various walls and ledges (phases C, D, E, F) 
As we had done when teaching her to get out of her chair, 
we required her to stand and walk increasing distances before 
she received her food. During the latter portion of this 
program, her trainers would no longer help her up when they 
arrived for her mealtime sessions, requiring her instead to 
employ her new skill. 

During the final two weeks of the program, we noticed 
that she was barely using the walls and ledges for assistance. 
We therefore added a new program, requiring her to stand 
entirely unassisted. She used the same basic strategy that 
she had developed to get out of the chair, rocking forward 
with arms outstretched until the momentum brought her to her 
feet. During the first phase, we delivered the food as soon 



100 



as she was standing [Figure 16, phase A). For the next nine 
weeks, we conducted the session almost daily, requiring her 
to walk three or four steps for food (phase B) . Thereafter, 
we maintained the session sporadically eventually delivering 
the food on a VR2 , then VR3 schedule (i.e., food on an aver- 
age of two, then three trials; phases C, D) , When we elimi- 
nated the program altogether, she was able to stand up about 
ten times per minute, for three minutes at a time. Although 
one might have expected the variable food-delivery schedule 
to maintain a higher response rate than that maintained by a 
continuous schedule (Reynolds, 1968), such was not the case 
in Claudia's stand-up program. She was probably not physically 
capable of executing the performance faster than ten times 
per minute. Neither was I: Matching her stand-up for stand- 
up, I was embarrassed to discover that I looked considerably 
worse for wear than did she, and I was not simultaneously 
trying to chew and swallow. 

The Daily Constitutional, Part I 

About a month after we began the between-chairs walking 
program, we realized that while Claudia was progressing 
nicely, she was not getting very much practice. Most of the 
walking was in a straight line, met by food at each stop. 
The remainder of her walking occurred in the cottage and 
covered very short distances. We had taught her the skills 
necessary for more extensive v;alking, but she did not use 
them. If her walking was ever to amount to anything, we 
clearly had to expand her training. 



101 



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102 



The afternoon was the best time for such., an undertaking, 
since she was with Julia for a large portion' of the morning, 
and we went home shortly after supper. Our training building 
was located several hundred yards from the cottage and seemed 
a likely target. It was August, and th.e air conditioned 
building offered a break from the vicious heat before the 
return to the cottage. The building was also stocked with 
enough balls to amuse Claudia for hours. We knew that Claudia 
could not make the entire trip on her own, and v/e therefore 
abandoned our policy of providing no assistance. By this 
time, she was walking fairly proficiently inside the cottage, 
and we gambled that providing assistance during her walk 
would not affect her indoor program. We gambled correctly, , 
but it was small consolation for Georgianne, who spent the 
hottest summer of her life between Lilac and the STARS build- 
ing. Everyday she and Claudia left from Lilac's backdoor and 
followed driveways, streets, and sidewalks to arrive exhausted 
at our building (Figure 17) . 

Some parts of the route were rougher than others, and in 
these Georgianne held Claudia's wrist firmly. In the smoother 
sections, Georgianne walked close behind Claudia, and when 
she began to sit down, Georgianne held both her arms straight 
up to prevent sitting. Georgianne would then do her best to 
start Claudia walking again, supporting Claudia by the arm.pits 
and moving her for^vard, ' If repeated attempts to initiate 
walking failed, Georgianne took Claudia's wrist and assisted 
her until Claudia was walking smoothly again, ready for another 



103 




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104 

try at independent walking. They both rested every few hundred 
feet. Georgianne counted the number of independent steps and 
attempts to sit down on the way to the STARS building (Figure 18, 
phase A). A one-way trip was enough, perhaps too much, and 
we returned Claudia to the cottage by assisting her throughout 

the walk. 

A one-way walk required about 1300 of Claudia's small 
steps, and during the first two weeks the only change was in 
the condition of Georgianne' s back. Georgianne therefore 
devised a new, less taxing procedure, placing her knee under 
Claudia's seat to prevent sit-downs (phase B) . Both her back 
and Claudia's walking improved. Claudia averaged nearly 350 
independent steps per journey, more than twice as many as 

before. 

In September, we added several features to the program, 
and the sitting improved further. Claudia's parents bought 
her a new set of tennis shoes to replace the worn-out, 
heavier saddle shoes in which she had learned to walk. 
Georgianne also brought a ball along for the walk which she 
placed 200 feet ahead of Claudia for use during rest breaks. 
The most significant change was probably the new route we 
chose, leaving from Lilac's front door and following sidewalks 
most of the way. The number of independent steps jumped to 
over a thousand, and within five weeks Claudia could walk 
most of the route on her own (phase C). The number of attempts 
to sit down changed little over the course of the program. 
This was further evidence of Claudia's progress, since there 



105 




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was one attempt for eacii twenty-five independent steps when 
she began and one in 250 in the latter portion of the program. 

The Daily Constitutional, P art II 

Georgianne left the STARS Program in late September, and 
I continued the after-lunch walking sessions while inter- 
viewing applicants for the vacant position. I hired Cindy, 
who tolerated the walking sessions for about a month before 
pointing out a problem. Hadn't I noticed that Claudia's 
attempts to sit down no longer appeared when she encountered 
rough spots enroute to our training building? Rather, 
Claudia would turn to walk in a different direction; we would 
re-orient her toward our building; and only then would she 

sit down. 

It was true; I had fallen into a rut. In my desire to 
see Claudia walk to the STARS building without any assistance, 
I had not considered alternatives to the daily ritual. 

we let Claudia choose the direction of her daily con- 
stitutional. AS long as she walked for about half an hour 
each day, we didn't care where the walks occurred. In fact, 
the new policy had many advantages, Claudia learned to walk 
on grass, dirt, bumpy streets, and the like, without explicit 
programming. Her trainers were pleased, as they had an op- 
portunity to explore other parts of the campus. We expanded 
the session to included short strolls ^fter breakfast and 

dinner. 

Claudia became increasingly attentive to the environment. 

She began looking aroan.d her, at people, moving vehicles, and 



107 



objects and buildings, Her favorites were the small, manually 
operated merry-go-rounds that were located in almost every 
playground. She would spot one of these from several hundred 
feet away and walk over. We could spin her until we were 
exhausted; the faster we pushed, the more she laughed. In 
inclement weather, she frequently walked inside the campus 
hospital, where she was a welcome visitor. She rode the 
elevators and walked endlessly up and down the halls, ex- 
ploring the wards and lounges. Many of the staff had known 
her before, and their exclamations at the change in her made 
us redouble our efforts. 

We 'tried a number of recordkeeping formats to monitor 
her progress, and after several months settled on a general 
measure of assistance. Her trainers counted as an assist 
any instance in which they either had to catch her to pre- 
vent her from falling, or give her a small push when she 
balked at something in her path. The assists gradually de- 
creased from about one every two minutes to about one in 
twenty minutes, or several per walk (Figure 19). I purchased 
a pedometer to obtain a measure of distance, but the records 
were unreliable due to her swaying gait. We eventually merely 
recorded the amount of time she spent walking each day and 
kept a log of the places she went. These were sufficient 
to keep track of the program, 

Claudia's hands and arms also provided us with an informal 
measure of her improvement. During the early stages of walk- 
ing, she always kept her hands up and out to her sides, arm.s 



108 




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109 



flexed at the elbow. Over the months, she gradually lowered 
her arms. Eventually, she walked with them hanging loosely 
at her sides, raising them only when crossing rough terrain. 

In the early part of the program, Julia continued to 
take Claudia out in the wheelchair. We did not object. 
Keeping Claudia on the move was strenuous work, and Julia 
was elderly. However, as the walking improved, the other 
foster grandparents chided Julia, who eventually succumbed to 
peer pressure and abandoned the wheelchair. This pleased us 
immensely, since V7e knew that we would eventually have less 
time to spend with Claudia. .We now had a guarantee that the 
walking would be maintained. Further, we did not have to 
push for the change; the goad had come from others who had 
noticed Claudia's progress. 

Auxiliary Skills III: Climbing Stairs 

During the last few weeks of Claudia's walks to our 
training building, she seemed sure-footed enough to learn to 
walk up and' down stairs. Because of the operation, her rigid 
ankles would probably never allow her to scale steps without 
support. However, teaching her to use a support rail or 
bannister seemed a reasonable goal. 

The front steps of Lilac were a likely beginning. There 
were only three shallow steps, each three and three-quarter 
inches high, leading to the porch v/hich was surrounded by a 
steel rail. The rail terminated at each side of the top step, 
and, although there was no bannister, Claudia could easily 
reach the rail from the foot of the steps. 



110 

We had previously been assisting Claudia whenever she 
encountered steps, holding both her hands tightly and bracing 
her against us. We had noticed that it was easier to help 
her up the steps than down, so we began by teaching her to 

go up. 

Since we had always assisted her ourselves, our first 
task was to teach her to grasp the rail. We started her on 
the sidewalk about five feet from the bottom step, had her 
walk to the foot of the steps, lean forward and grasp the 
rail, whereupon she received the familiar spoonful of food. 
She learned to grasp the rail with both hands within a week, 
and we began working on the actual step-climbing. 

We continued the procedure as before, giving her a five- 
foot start, but now we walked ahead . of her and waited on the 
top step. We counted the number of stairs she scaled, start- 
ing the timing on each trial when she began walking and turn- 
ing off the watch when she had both feet on the top step. She 
learned the skill quickly, increasing from the original nine 
stairs per minute to fifteen stairs within several weeks 
(Figure 20, phase A). We worked next on walking down, giving 
her food at top and bottom, but counting and timing only while 
she descended (phase B) . We then briefly returned to moni- 
toring only while she walked up (phase C) , to be sure she 
had not lost her former speed in this component. We completed 
the program by recording the rate at which she both ascended 
and descended the stairs (phase D) , 



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Claudia was ready for a new set of steps, but none were 
to be found. Due to her limited walking, there were no other 
stairs with support rails v/ithin easy access from Lilac, so 
the program was temporarily stalled. Her trainers worked 
with her on stairs they encountered during her after-meal 
strolls, but we did not wish to feed her at these times, and 
without food, getting her to climb was usually a struggle. 
We ordered a set of wooden playground stairs, with five six- 
inch steps and support rails. While we awaited delivery, we 
continued to practice on the front steps of Lilac. 

When the new set of steps arrived, Claudia both ascended 
and descended them as well as she could the cottage's more 
shallow front steps, probably because of the bannister. She 
received her food after completing all five steps. There was, 
however, a new problem. When walking up, Claudia frequently 
took two steps at a time, and in doing so occasionally tipped 
backward. To eliminate the behavior, we blocked with our feet 
each attempt to take two steps, pushing her feet back to the 
appropriate step. The attempts slowly decreased as she learned 
to climb the steps more rapidly, beginning at about twelve 
stairs per minute and increasing to over twenty-five. We began 
using the left side (facing) bannister and later switched to 
the right side (Figure 21, phases A, B) . 

Claudia descended the steps only slightly more slowly 
than she ascended them. She did not attempt more than one step 
at a time, but at first required her trainers' assistance to 
keep her hands on the rail and to keep moving (Figure 22, 



113 





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115 



phase A) . She soon needed no assistance, and we proceeded 
in the same manner as in the up- steps component, using the 
left, then right rails (phases B, C) . 

By the time Claudia reached what was apparently her top 
speed on the playground steps, her walking speed and balance 
were sufficient to permit us to find new stairs for practice. 
The hospital had several outdoor staircases with rails, and 
we made use of these, practicing on each set until she 
climbed up at the rate of at least twenty steps per minute 
and down at at least fifteen. 

Her proficiency was reflected in her after-m.eal walks. 
We no longer had to struggle with her to climb stairs, even 
when no food was in the offing. The skill opened new avenues 
of exploration for Claudia and made our time with her far 
more pleasant. 

Auxiliary Skills IV: Crossing Obstacles 

Although Claudia was learning to walk over many surfaces, 
any transition (sidewalk to grass, etc.) or obstacle higher 
than about one inch caused her to stumble or to stop walking 
and hold out her hand to her trainers. She was improving, 
but we sought to speed up the process by carefully programming 
a series of obstacles of known dimensions. As she became 
proficient at crossing each, we added to it, increasing the 
difficulty only slightly. We ordered a set of boards which 
arrived in August, 19 77, at the same tim.e as the playground 
steps. 



116 



We conducted the session in much the same manner as we 
had the between-chairs walking, placing two chairs eight 
feet apart on the sidewalk in front of Lilac. The first 
obstacle was a single board, one and a half inches high and 
three and a half inches wide, centered on the walk between 
the chairs. She walked from chair to chair ten to fifteen 
times, receiving her food and a brief rest at each stop. We 
counted the number of times she crossed the boards, operating 
the stopwatch between the time she left one chair and ar- 
rived at the other. We counted an assist if we had to push 
her when she balked, or if she bent over and used her hands 
to help herself clear the board. She learned to cross the 
board quickly (Figure 23, phase A) , and we moved the chairs 
eleven feet apart, placing another board parallel to the first 
and centering both between the chairs. Again she performed 
well (phase B) . 

We increased the height of one of the boards to three 
inches, leaving the other at one and a half inches. The 
number of assists rose sharply, but declined within a week 
(phase C) . We continued the sequence by increasing the height 
of the second board to three inches, but Claudia apparently 
disagreed with our logic. The number of assists, which began 
at one in every ten boards, increased to an assist for every 
other board (phase D) , I briefly tried replacing the second 
board with one only one and a half inches high, but v/ithin 
several trials, I could see the problem had not disappeared. 
I removed the smaller board entirely and centered the single, , 



117 




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three inch board between the chairs. We retained this 
configuration for five weeks (phase E) , then successfully 
added the second, one and a half inch board (phase F) . 

I was unwilling to increase the height of the second 
board to three inches and risk failure a second time. In- 
stead, I changed the obstacle from a board to a small plat- 
form, two and a quarter inches high and one and a half inches 
wide. This was considerably more difficult than the previous 
task, requiring Claudia to step up on the platform, gain her 
balance, and then step down. I therefore changed our policy 
of providing no assistance except a gentle push. Each time 
she approached the board, I placed my thumb and index finger 
under her right wrist to help her balance. I did not want 
to hold her hand, fearing that it would be difficult to 
gradually reduce the amount of assistance. She rapidly 
learned to get up on the platform, and stepping dovm was never 
a problem. I assisted her in this manner on almost every at- 
tempt, although several times she was up on the platform 
before I was ready for her (phase G) . 

Fortunately for Claudia, I had to leave for several days, 
and Kris, a new trainer, conducted her sessions. Through a 
miscommunication, Kris thought that she was supposed to assist 
Claudia only when Claudia balked at the platform. This, in 
fact, was all the help that Claudia needed, and we continued 
to train under the new policy (phase H) , ' We successfully 
raised the platform to three inches (phase I) , then four and 
a quarter inches (phase J) , 



119 

Claudia's walking skills had progressed markedly. She 
balked at fewer obstacles and crossed rough terrain more 
easily. The improvement was most obvious when she encountered 
low curbs. Prior to her training with the platform, she had 
never surmounted a curb on her own. When the platform height 
reached three inches, we could induce her to scale the curb 
with a bit of gentle pushing, and when the platform was raised 
to four and a quarter inches, low curbs were no longer a 
problem. 

Claudia could truly walk by herself. 

The Campus Cafeteria 

Getting There 

Marsha left the STARS Program in mid-November, 1976. 
During her last week with us, she instituted a change that 
affected the entire program. We had just eliminated Claudia's 
walk from Lilac to our building. If Claudia could now walk 
where she pleased, Marsha reasoned, why couldn't she walk to 
the campus cafeteria? It was located less than two hundred 
yards from Lilac. As much as Claudia enjoyed eating, it 
should not be difficult to induce her to make the short trek. 
Her feeding skills were hardly polished, but she could handle 
a spoon, and the relaxation chair was adding nothing to the 
program. 

The change was miade and Marsha departed for her new job. 
Cindy, Mardi , who replaced Marsha, and I were left to continue 
the program. Once again, the unexpected happened. Claudia 



120 



might walk well after meals, when she chose the direction, . 
but going to the cafeteria was another matter. Once there, 
she seemed to enjoy it, making her excited noises and gestures 
smiling and laughing at all the activity. But we had to 
struggle to get her there. Perhaps it was because she had 
always eaten at the cottage and then gone for her w-alk; we 
were attempting to leave Lilac before she had eaten. Most of 
her struggling and attempts to sit down occurred on Lilac's 
front sidewalk. Once past the walk and away from Lilac, the 
going was easier. 

We considered taking food or juice to feed her periodi- 
cally along the way, but decided against it. She had been 
walking considerably further without food for several months 
and adding food now would be a step backward. This was 
probably an incorrect decision. We assumed that she could 
make what was for her a relatively long journey because there 
was food at the end of it. How could we expect her to make 
the whole journey right from the start? We had worked with 
her for almost a year, painstakingly building each skill a 
little bit at a time. Now we were trying to effect a major 
change with no preparation ^t all. Claudia's trainers some- 
times learned as slowly as did she. Nevertheless, we kept 
trying, using the same procedure as we had during Claudia's 
walks to our building, and finally succeeded. After several 
months, Claudia walked the entire distance without help or 
urging from us. Eventually she laughed and walked at her 
maximum speed, a hundred and forty feet per minute, en route 



121 



to eat, coming as close as she ever did to actual running. 
Meanwhile, the rest of the STARS Program followed our 
lead. In tim.e , most clients who learned basic feeding skills 
began eating at the cafeteria. It was a pleasant and re- 
warding change from the confines of Lilac for clients and 
trainers alike. 

Eating Skills in the Cafeteria 

During the first six months in the cafeteria, we did 
nothing more than continue Claudia's scooping program. We 
were assisting her with every scoop when we arrived and later 
assisted her only when necessary (Figure 9, pp. 63-66). As 
her walking was still rather limited, we did not attempt to 
have her go through the food serving line. Rather, we seated 
her, brought her her food, and returned her tray to the dis- 
posal window after the meal. 

By the end of June, 1977, Claudia could use her spoon 
with little assistance. We decided that it was time for her 
to learn to use a fork. Forks had not been available at Lilac, 
but they were at the cafeteria. Many of the higher level 
clients at the cafeteria could not use forks, but the pro- 
gram seemed worthwhile since many items, such as salad, were 
more easily stabbed than scooped. 

During each meal we allowed Claudia to eat most of her 
food with her spoon, setting aside any chunks that would be 
easy to stab with a fork. Vie then placed the fork in her 
hand and assisted her in stabbing the first few chunks. 
Thereafter, we gave her an opportunity to stab each piece. 



122 



If she failed after several attempts, or if she tried to 
scoop' with the fork/ we assisted her in stabbing that chunk. 
The strategy did not work. She was not putting any force into 
her stabs and rarely succeeded in spearing her food (Figure 24) 
We tried assisting her with every chunk for the next two 
months, but we observed no increase in force. She was no 
closer to success than she had been when we started the pro- 
gram, so we terminated it. Using a fork was not vitally 
important to Claudia's eating skills, but our failure to 
teach her was yet another disappointment in this difficult 
area of her training. 

We met with considerable success, however, in teaching 
Claudia to handle her cup. We had always assisted her with 
this task, since if we did not, she would pick up her cup, 
take a drink, and then drop the cup, whether or not liquid 
remained in it. Claudia normally paused only two or three 
times while drinking, giving us few opportunities to replace 
the cup on the table. To increase the number of opportunities, 
we placed only a sip or two of juice in the cup for each trial. 
For three weeks, we allowed her to pick up the cup and drink 
the juice by herself. As she brought the cup away from her 
mouth, we grasped her wrist firmly and guided her hand to 
place the cup upright on the table, releasing her wrist when 
she had released the cup. At first we had to do all the work; 
we could feel the resistance as we guided her hand. Gradually 
the resistance decreased and at the same time she learned to 
release the cup as soon as she had placed it on the table. We 



123 




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replaced the all-assisted procedure with one in which she was 
given the opportunity on every trial to replace the cup on 
the table by herself. If she dropped the cup or set it dov/n 
sloppily so that it tipped over, we counted an incorrect 
response, replaced the cup in her hand and assisted her to 
set it down correctly. During the next two months, the 
incorrect cup placements decreased from about one in every 
four attempts to fewer than one in twenty (Figure 25) . We 
could then safely give her the entire cup of liquid at once. 
She never dropped it, but she occasionally set it down on 
top of her silverware, allowing it to tip over. This hap- 
pened rarely, and the mess created was well within the limits 
tolerated by the campus cafeteria, where spills, dropped 
trays, and other accidents were a common occurrence. 

Claudia also spilled a considerable amount of liquid 
while she drank. She held the cup at too sharp an angle and 
frequently left it there when not swallowing, allowing the 
juice to run out of her mouth and onto her bib. We never 
succeeded in eliminating the spills, but the amount of 
liquid spilled decreased sharply after she learned to handle 
the cup. After that program was terminated, she always 
lowered the cup when not actually drinking. Interestingly, 
she did not replace the cup on the table during each pause, 
a by-product we were afraid the program might have produced. 
Rather, she often lowered the cup mom.entarily , then resumed 
drinking. She was not exactly fastidious, but she could 
definitely drink without our assistance. 



125 



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The Serving Line and Carrying the Tray 

In late 19 77, when Claudia had been eating at the 
cafeteria for about ten months, her walking skills were 
advanced enough to allow us to teach her to carry her tray. 
We designed two programs, one to occur in the cafeteria at 
mealtime and one to take place at Lilac. 

When we arrived at the cafeteria, we seated Claudia and 
took a place in line. At the head of the line, we brought 
Claudia over and assisted her through the entire process, 
guiding her hand to take silverware, dessert and main course 
dishes, and a drink. We used spoonfuls of food to induce her 
to push her tray, replacing her hands on the edges and prompt- 
ing her to push when necessary. At the end of the serving line 
we stood behind Claudia, made sure she was grasping the tray 
firmly, held the tray lightly ourselves, and guided her to . 
the nearest table. After the meal, we used the same proce- 
dure to guide Claudia to the disposal window. We reserved 
more intensive training for extra sessions at Lilac. The 
cafeteria was crowded, and we did not wish to add to the 
confusion with the dropped trays, spills, and stalls we knew 
would accompany the program. 

The kitchen counter in Lilac, about ten feet long, was 
perfectly suited to our purposes. We placed a bowl of blend 
on a tray, arranged Claudia's hands on the edges, took the 
spoon, and had her follow us, sliding the tray. When she 
reached the end of the counter, she picked up the tray and 
carried it back to the starting point, ready to begin the 



12 7 

next trial. We conducted. about fifteen trials per day. At 
the beginning of this portion of the program, we gave her 
two spoonfuls of food per trial, one about half v;ay down the 
counter and one when she returned to the starting point. 
After several weeks, we gave her only one spoonful at the 
end of each trial. We assisted her when necessary, replacing 
her hand on the tray as she pushed it or leveling the tray if 
it tilted while she carried it. At the beginning of the pro- 
gram, we were not always as quick as we should have been and 
had to clean and mop the kitchen floor regularly. Our assists 
gradually declined to one or two per session, while her rate 
of trial completion (we timed only during trials) rose from 
less than two per minute to approximately five per minute 
(Figure 26, phase A). By the end of this training phase, we 
no longer had to prompt her to push the tray in the cafe- 
teria line, so we concentrated on teaching her to carry it. 

Claudia now carried the tray from the end of the kitchen 
counter into the hall, to the clothes dryer, about fifteen 
feet away, where she received her food. Each session con- 
sisted of about fifteen trials, or one-way trips. We as- 
sisted her in leveling the tray whenever the bowl of blend 
began to slide (phase B) . Although she rarely tilted the 
tray enough to dump the blend before we could catch it, we 
were not satisfied with the program. The blend bowl was too 
heavy to be a sensitive, reliable indicator of tray tilt, and 
we could not trust our vision because the tray jiggled con- 
siderably when she walked. We solved the problem of finding 



128 



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129 



a sensitive, mess-free, criterion by placing a steel weight 
in the bottom' of a plastic cup. The cup and anchor weighed 
about six ounces, enough weight to prevent the cup from top- 
pling at the slightest jostle. When the cup did fall, we 
righted it, adjusted the angle of the tray, and counted the 
occurrence. As Claudia gained speed carrying the tray, the 
cup fell less and less often (phase C) . When the cup was 
falling less than once per ten carries, we replaced the steel 
weight with a wood block, decreasing the total weight to 
about three ounces (phase D) , then used an empty cup, which 
weighed two ounces (phase E) . 

In the cafeteria, we stopped "shadowing" Claudia and 
holding her tray at the same time we replaced the steel weight 
with the block. However, we remained only inches from her as 
she carried the tray to her table, or to the disposal window 
after meals. When the block was removed from the cup, we 
were able to stand several feet from Claudia in the cafeteria. 
She did occasionally dump the tray, but accidents of this 
nature occur periodically among all but the highest- level 
clients. As was also common practice among the cottages 
attending the cafeteria, vie carried Claudia's juice cup for 
her when it was filled to the brim: We could not reasonably 
expect her to perform a task that we ourselves had trouble 
executing. 

We were unable to teach Claudia to go through the serving 
line independently. She eventually learned to pick up silver- 
ware, but never discriminated knife," .fork, and spoon. Without 



our assistance, she put her hands into one of the bins and 
extracted one or more of whatever happened to be in that bin, 
but there the learning ceased. Progressing through the line, 
she usually needed assistance to take the food dishes. The 
assistance usually consisted of pushing her hands toward the 
dishes. Once aimed in the right direction, she would usually 
take the dish, occasionally requiring additional assistance to 
place it on the tray v^ithout spilling the contents. 

Watching Claudia go through the serving line and take 
her tray to the table, I thought back to the time, a year and 
a half earlier, that we began walking her to the cafeteria. 
It had been such a struggle to make her v/alk that we had 
nearly abandoned the program. How unfair to her it v/ould have 
been had we done so. 

Final Aspects of Training 

Exploring Out the Gate 

Ask a "high-level" where he or she would like to go, and 
the answer is frequently "out the gate," The Sunland campus 
is neither locked nor hidden behind massive walls. It is, . 
however, bounded by fences, and many clients rarely leave the 
premises. Going out the gate is a treat — a shopping trip or 
an afternoon of bowling with a volunteer sponsor, or a group 
outing to a concert or sports event. Advanced clients earn 
special status by attending off-campus schools or by gaining 
employment in the com.munity, and the most advanced can leave 
the campus permanently to reside in a group living home. 



131 

Our clients had seemed to enjoy the first off-campus 
picnic at the lake/ and field trips became an important part 
of the STARS Program. Although the clients were nonverbal 
and could not ask us to take them out the gate, their ex- 
citement as they boarded the bus on Saturday and Sunday morn- 
ings was proof enough, and several of them invariably became 
sullen and cried when we returned to the campus. 

The field trips were a welcom.e break in routine for both 
clients and staff, and provided a chance to practice newly 
learned skills in novel environments. For those of us working 
with Claudia, the field trips were a way to watch her grow. 
We brought a wheelchair for her on the first picnic; we had 
just begun her walking program, and she took but a few inde- 
pendent steps in the grass at the lake. The wheelchair was 
soon unnecessary, and, with her trainers' prompting and coax- 
ing and with frequent rest breaks, she was able to keep pace 
with the expanding scope of STARS field trips. We attended 
local events such as parades and the circus, visited parks 
and other attractions, and ate at several restaurants. 

During this time, the number of stimuli to which Claudia 
responded increased m.arkedly. Loud noises, m.usic, brightly- 
colored fast-moving objects, and large groups ■ of people 
attracted her attention. She watched intently, grew excited, 
laughed, and walked without prompting to explore her surround- 
ings. Her love of motion, which we had discovered when riding 
her in the relaxation chair, continued. Rides at carnivals 
were the most exciting, but she even enjoyed the bus rides. 



132 

laughing at the sight of the bus parked at Lilac's, back door. 
i\s she progressed in !ier ambulation training, she learned 
to board the bus and seat herself without assistance. 

In the spring of 1977, a year after the first picnic, the 
STARS took an all-day trip to Disney World. It was a big 
event for us and required all the skills we had taught our 
clients. Watching Claudia walk through Disney World and 
enjoy the attractions, I could see clearly the effects of 
her intensive training. It was a fine professional reward. 

Expanding the Daily Constitutional 

Marsha returned to work in the STARS Program just before 
the trip to Disney World. Although she had visited periodi- 
cally during her absence, her new, close contact with Claudia 
provided her an excellent perspective for comparison. When 
she had left the program, Claudia was slowly, painfully 
learning to walk to the cafeteria. Noting the improvement in 
ambulation skills and, particularly during the day at Disney 
World, Claudia's progress in other areas, Marsha suggested 
that we begin taking Claudia off-campus more frequently. 

Claudia's afternoon walking session, which originally 
seemed to offer an endless supply of new environments, had be- 
come somewhat confining. Claudia could walk to almost any 
point on campus, limited only by time. Interspersing off- 
campus trips with these walks would provide a fresh supply of 
novel situations. A five-to-ten minute drive gave access to 
a variety of parks, playgrounds, shopping areas, and local 
events. Riding in the trainer's car was, of course, half the fun, 



II 



133 



We maintained data regarding the off-campus trips in 
the same fashion that we monitored her on-campus walking, 
keeping a chart of walking time and a log of places visited. 
The number of stimuli to which Claudia was exposed multiplied 
dramatically. 

Social Behavior 

During my time with her, Claudia made many changes be- 
sides those described in the preceding pages. These changes 
are perhaps best labeled as social behaviors or "responsive- 
ness to others »" Although these changes were among her most 
important and advanced accomplishments, we unfortunately did 
not quantify them for a variety of reasons. As other researchers 
(e.g., Harris et al. , 1964; Risley, 1968) have found, the 
social behaviors emerged largely as a by-product of her train- 
ing and as such were never monitored closely. We were often 
unaware that a behavior was emerging or changing until the 
change was so obvious that we could not have ignored it had 
we tried. The lack of data deprived us of an opportunity to 
study the development of the new behaviors, but we apologized 
to ourselves by noting that our measurement and training ef- 
forts were directed to the more immediate priorities of ru- 
mination, ambulation, feeding, and the like. We did not know 
why these other changes occurred but were grateful for them. 

During my last year in the STARS Program, Claudia began 
to laugh considerably more often and began, albeit infre- 
quently, to respond to her name. On her walks she gradually 



134 



began to follow her trainers; earlier, we constantly had to 
physically steer her in the desired direction. 

Most notable was the change in the amount of physical 
contact she had with us. Many of the trainers would gather 
after meals in Lilac's lounge or outdoors to relax, monitor 
the clients for self-abuse, and to give the clients extra 
time out of the cottage. During these times we played with 
Claudia, tousling her hair, patting her stomach, and other- 
wise physically interacting with her. Claudia was originally 
indifferent to these overtures, ignoring them or pushing our 
hands away, preferring instead to bounce her ball. Gradually, 
she began to tolerate the contact and then to seek it. If we 
seated her across the lounge, she would walk over and sit 
beside one of us, taking our hands in hers and placing them 
on her head or face. 

When we finally became aware that these social behaviors 
were emerging, we undertood to teach a specific response, , 
hugging. To our discredit, we again failed to collect quan- 
titative data, and thereby deprived ourselves of yet another 
opportunity to study a significant aspect of Claudia's growth. 
The training was simple and informal. We took advantage of 
her newly acquired behaviors of approaching and touching us. 
At various times while she walked, her trainer walked ahead 
of her, then stopped and v/aited. She generally walked up to 
the trainer and stopped. When she did so, the trainer bent 
down and placed her arms in hugging position, directly around 
the back. The trainer reciprocated the hug, patting her back 



13; 



lightly for a few seconds, then resumed the walk. We were 
quickly able to eliminate physical assistance. Within 
several weeks we needed only to tug lightly at her arms or 
gently nudge her elbows to initiate a hug, and even these 
prompts were soon rarely necessary. 

Of all Claudia's trainers, I was the slowest to recog- 
nize the significance of these new behaviors. Immersed in 
monitoring her progress in her regularly scheduled program.s, 
I failed at first to realize that the new behaviors, parti- 
cularly the hugs which we had specifically shaped, were 
different than other behaviors we had trained. Conspicu- 
ously absent were the usual reinforcers^ — the opportunity to 
leave the cottage, riding motion, and especially food. Rather, 
our physical contact with her appeared to function as the 
reinf orcer . 

Sitting with her in the cottage one night, I sought to 
confirm this observation partially by calling upon her old, 
familiar "eye contact" response. I picked her up, swung her 
around several times and roughhoused her, making her laugh and 
grow excited. I reseated her and told her, "Look at me, 
Claudia." The unmistakable expression appeared; I hugged her 
for several seconds; and she began laughing again. I stood 
up and issued the command again. Once more she made "eye 
contact," and I hugged her; again she laughed. I repeated the 
sequence about ten times more, then attended several other 
clients for about five minutes, allowing her to settle down. 
I approached her again and this time I did not begin by 



136 



exciting her, rather beginning directly with the command to 
look at me. "Eye contact" followed the command almost im- 
mediately and continued to do so for perhaps another ten 
trials, at which time I terminated my "experiment." In 
retrospect, I could have obtained clearer evidence of the 
reinforcing nature of the hugs by engaging in more sophis- 
ticated behavioral analysis. I could have, for example, 
added another set of trials in which I ignored the eye con- 
tact, then performed a third set in which the hugs were 
reinstated ("ABA" design) , Other manipulations would have 
permitted more detailed exploration, such as isolating the 
relevant aspects of the hugs. 

Unfortunately, I did not pursue these avenues. The 
ideas did not occur to me at the time. I was too excited by 
the realization that Claudia had changed in a way that we had 
not even contemplated when we first observed her on the floor 
of Lilac. We had decreased the rumination and given her a 
variety of basic living skills. Now, she had developed 
social behaviors. They were perhaps rudimentary, but to us 
and to Claudia they made a difference. 

The Limits of Training 

We attempted to teach Claudia many things and obviously 
did not always succeed. In some cases, she learned well up 
to a point, beyond which she did not advance. In other cases, 
our basic or preparatory training failed, and we abandoned 



137 



altogether our efforts in those areas. There were also 
akills that we never even attempted to teach her. 

Whenever our training was styiriied, v/e had to ask our- 
selves whether the problem was our technique or whether the 
goal was beyond Claudia's capabilities. There was, of 
course, rarely a definitive answer. For alm.ost every failed 
strategy several alternatives were available. These we had 
to weigh against her previous progress in that area, her 
progress in other areas, and against considerations such as 
probable expenditure of time, energy and money. When we 
tried a new tactic and succeeded, we felt vindicated. When 
we elected to discontinue a program, we did so with reluc- 
tance. Perhaps another day or week would have made the 
difference. 

Review of Training Discussed Heretofore 

Teaching Claudia to eat independently proved more 
disappointing to us than any other area of her training. Per- 
haps this was because she learned the basic skill, scooping 
with a spoon, so rapidly. In comparison, her subsequent 
progress seemed incredibly slow, and in some areas she never 
progressed. After tv/o and a half years, we had succeeded in 
that she could independently eat her entire meal and drink 
her juice.' But there was also much she could not do. She 
still needed a bib to collect spilled food and liquid. Al- 
though she did not scoop backhanded, her forward scoops 



138 

pushed a considerable amount of food off the plate. We had 
failed in teaching her to use a fork, and, based on her 
loose grip of the fork and her limited maneuvering of the 
spoon, we had not tried to teach her to cut the food. With 
further training, she may someday eat neatly, without a bib. 
But is using a fork and knife a feasible goal? At the tim.e 
we tried to teach her, it was not. Perhaps the opportunity 
will arise again later, when she has had several more years 
of practice at eating by herself and if those v;orking with 
her at that time have found a more effective teaching tech- 
nology. 

Claudia progressed neither as far nor as fast as we had 
hoped after the first week of her scooping program. But 
when we first saw her lying on the floor of Lilac, we did 
not even contemplate teaching her to feed herself. Consider- 
ing Claudia's initial state, her feeding programs hardly 
failed. 

Her progress in the cafeteria must be viewed likewise. 
She could not go through the serving line by herself and, 
in fact, could not wait in line for more than a minute or 
two. Neither, however, could many of the other clients who 
lived in higher level cottages. Again, she may yet learn 
to do these things. In my training with her, she did not. 

In teaching Claudia to walk, the most successful of 
our training efforts, we also faced lim.its. I doubt that 
she will ever run, although her speed as she approached the 
cafeteria in mid-19 7 8 cast doubt upon this prediction. A 



139 



year earlier, the prediction seemed a safe one. The triple 
arthrodesis operation, as well as her small stature, also 
render unlikely the possibility that she will learn to climb 
or descend stairs without supporting herself on a bannister. 
However, she learned essentially the same behavior in her 
"obstacles" program; the five-inch platform was a shallow, 
wide step. How much further could the program be pushed? 
Claudia taught us that guessing does not provide the answer. 

Programs That Failed 

Self-care and hygience programs were neither Claudia's 
forte nor ours. We attempted a toothb rushing program, based 
on the observation that she enjoyed having her teeth brushed, 
or so we naively surmised. What she enjoyed was the tooth- 
paste. We began, as we did with most of her sessions except 
those dealing with walking, by physically assisting her. The 
simplest motion was side- to-side, but all attempts to fade 
the assistance produced the same result. Claudia was rapidly 
learning to chew her toothbrush. With this ignominious be- 
ginning, we terminated the program. Even if we could teach 
her simple brush strokes, how much longer would it take to 
teach her to brush her teeth in a manner that would do them 
some good? She would not benefit from what promised to be a 
long, frustrating program. Our efforts were better directed 
elsewhere . 

We abandoned the toothbrushing program after several 
weeks, but were more tenacious in attempting to teach Claudia 
dressing skills. T-shirts seemied the best place to start, as 



140 



pulling on a loose fitting T-shirt requires less force than 
do most articles of clothing. Pulling on a shirt also lends 
itself well to the popular "backward chaining" method (Bas- 
singer et al. , 1971; Sundel & Sundel, 1975), in which the 
complex behavior is divided into a sequence of simpler res- 
ponses. The last response is taught first, then the next- 
to-the-last response, and so on. The final response when 
putting on a shirt is to pull it down once it has been slipped 
over the head and arms. This was to be our first step in 
Claudia's program. Unfortunately, to pull the shirt down 
one must be holding it, which Claudia was not. For five 
m.onths , we labored to induce her merely to hold the bottom 
of the shirt. We gave up about four months after we probably 
should have. 

We did not attempt to teach Claudia any other dressing 
skills. In retrospect, we were probably mistaken. Pulling 
on socks, slipping on a coat, and other skills might have 
been far easier to teach than pulling on a shirt. That we 
did not attempt other dressing programs was no surprise. Our 
first, extensive efforts were thoroughly unrewarded. 

We were also tenacious-- and generally unsuccessful — 
in an area unrelated to basic living skills: visual assess- 
ment. When focusing on objects, Claudia's eyes diverged. 
Our observations indicated that she primarily used her right 
eye," and we sought to develop a rapid measure of visual acuity. 
We developed a task in v/hich she was to choose a plain, white 
block over a white block with a black spot. We failed in that 



14; 



we did not develop a quick measure of resolution acuity, the 
common means of visual assessment. However, we pursued the 
project for more than a year to teach ourselves about the 
experimental analysis of behavior. We eventually obtained 
a measure of visibility acuity (detecting the presence/ 
absence of a stimulus; Christman, 1971). The results are 
reported in the final chapter. 

Programs Never Attempted 

We taught — or attempted with varying degrees of success 
to teach-- Claudia many of the basic elements of human be- 
havior. However, we made none but the m.ost superficial 
efforts in two major areas, toileting and speech. 

When we arrived at Lilac, all but a few of the clients 
v/ere in diapers. We successfully taught basic toileting 
skills to some, but failed with others v/ho were generally 
higher level than Claudia. Toileting is not an all-or-none 
behavior. Accident frequency varies widely and can be sub- 
divided into urination and defecation accidents. Self- 
initiating may be beyond many clients' capabilities, but 
these clients can be taken out of diapers if they eliminate 
only when sent to the toilet on a regular schedule. Toilet 
training frequently requires intensive training for days , 
weeks, or even months. 

Based on our experience v/ith higher level clients, we 
felt that we would be using much valuable training time with 
Claudia in a program that offered little hope of success. To 



142 



keep her in or near the washroom for extended periods would 
conflict with her progress in walking. Further, we were 
actually making an effort to keep her out of the v/ashroom 
since she, like many clients, drank from the toilet. It was 
essential to keep the drinking to a minimum., both for health 
reasons and because excessive liquid increased the probability 
of rumination. 

We did, however, begin placing her on the toilet after 
meals to see if she might be susceptible to a schedule of 
regular sending. After several months, she was no more likely 
to urinate or defecate on the toilet than she was when we 
began sending her, averaging overall a fifty percent "hit 
rate." She showed no regular pattern of eliminating at other 
times during the day. We continued the practice of sending 
her, however, as it required little effort and did occasionally 
save a diaper change. 

We held little enough hope for toileting, but even less 
for speech. Claudia was not deaf, as she demonstrated when 
the cottage door opened at meal times. She certainly vocalized, 
gurgling and crying at first, and later also laughing, but the 
range of vocalizations was quite limited. Despite our strenu- 
ous efforts to teach her to respond to her name, she responded 
to it only occasionally after hearing it repeatedly for several 
years. Our voices never exerted any consistent control over 
her behavior. In short, we had observed that som.e behaviors 
were likelier to occur than others, and speech was not one of 
the likely ones'. 



143 



Deterraining the Limits of Training 

Were the STARS Program to continue indefinitely, how much 
more could Claudia learn? The preceding sections contained 
speculation regarding training limits, but a definitive an- 
swer is impossible. Victor, the Wild Boy, was still learning 
when Itard terminated training after five years. Stoddard 
did not find learning limits with Cosmo, the microcephalic, 
after ten years (p. 18, ff.). Claudia's progress during tv/o 
and a half years is perhaps only a beginning. 

When we began teaching Claudia, our sole concern was to 
stop the rumination, and we gave little thought to what miight 
follow. Despite our naivete, we realized that Claudia was 
exceptionally low functioning, even among the profoundly re- 
tarded. Thus, v;e expected little of her. Our initial goals 
for many other clients included basic speech, refined speech, 
toileting, and academic and preacademic tasks. For Claudia, 
eye contact was the first step, and that proved to be too 
complex. Had we speculated during the first months of train- 
ing, we would not have included walking to the cafeteria and 
carrying a tray filled with solid food am^ong a list of feasible 
goals. But Claudia v/as full of surprises, and the surprises 
never ceased. We did not anticipate the speed with which 
she acquired basic feeding and walking skills early in her 
training; her social behavior was a later -surprise . As long 
as the surprises continue, we cannot know- what Claudia's 
limits are. 

The surprises do, however, suggest a rudimentary 



144 

criterion for predicting when the limits are reached. The 
criterion is simply the cessation of surprises. When one has 
"tried everything and nothing works," one can reasonably 
speculate that the limits are near. A surprise negates the 
speculation; lack of a surprise supports it. 

One reduces surprises by carefully monitoring data, and 
therein lies a more precise method of ascertaining the limits 
of training. As one teaches a behavior or set of behaviors, 
the following questions arise: Is there a change in behavioral 
frequency ("celeration" ; see Pennypacker, Koenig, & Lindsley, 
1972); that is, is the rate of appropriate behavior increasing 
and/or the rate of inappropriate behavior decreasing? Is it 
possible to successfully institute phase changes requiring 
new or refined responses? If cueing or physical prompting is 
used — as was often the case with Claudia-- can the prompt 
be successfully faded? Will the behavior occur in conditions 
other than training conditions, with or without explicit 
programming? Have all reasonable tactics been tried to induce 
the changes described in the foregoing questions? 

Applying the analysis to one aspect of her ambulation 
training, the obstacles program (pp. 115-119 and Figure 23), 
we clearly did not approach Claudia's limit. We were able to 
introduce many phases requiring successively more complex 
behaviors. Within most of the phases, the frequency with which 
Claudia crossed the obstacles either accelerated or maintained. 
Simultaneously, the frequency of assistance 'decelerated. Al- 
though we did not monitor with charted data her proficiency 



145 

at crossing obstacles outside of the session, we noted that 
she began independently stepping up curbs following her 
training with a similar obstacle (the platform) , In short, 
the rate at which Claudia learned new obstacle-related be- 
haviors gave us no reason to believe that we were approaching 
her maximum possible performance. 

In contrast, consider the data obtained during her fork 
program (pp. 121-123 and Figure 24). We tried two unsuccess- 
ful procedures. Although she was occasionally able to stab 
her food independently, the frequencies of independent and 
assisted stabs did not systematically change. Had we found 
a behavior that Claudia could not perform? We pursued only 
several of many possible training tactics. The data there- 
fore suggest, but hardly confirm, a limit. 

Similar analyses could be performed upon each program 
in each aspect of Claudia's training. In some areas, we 
possibly reached limits; in others, not. Our data, which 
guided us throughout Claudia's training, led us to the notion 
that "impossible" was not a viable concept. We tried, not 
always successfully, to approach each new programi with no 
preconceived notion of what she could learn. We occasionally 
got nowhere. More often, Claudia rewarded us handsomely. 



146 



Saying Goodbye 

The Author Leaves the STARS Program 

In the spring of 19 78, two and a half years after we 
created the STARS Program, I was given an opportunity to 
participate in a research project in another state. Saying 
goodbye to staff and clients was difficult. We were a tight- 
knit group and proud of the gains for which we had worked so 
hard, I fretted over the clients under my care and reviewed 
the program logic and procedures with those who would now be 
responsible. 

I worried least about Claudia's training, which was to 
become Marsha's responsibility. Marsha and I had worked to- 
gether in planning Claudia's training since the beginning of 
the program, and there was little to do except discuss pos- 
sible future teaching efforts. Lorrie, Mardi, and Maureen, 
who had worked extensively with Claudia, were still in the 
program, and many of the remaining staff were also familiar 
with Claudia. She would be left in competent, caring hands. 

In fact, my only major concern was a selfish one. I did 
not want to leave my friends; I did not want to leave my 
clients, I especially did not want to leave Claudia, Her 
progress had far exceeded my expectations, and she was still 
learning. I wanted to know how much more she could grow, and 
I wanted to be instrumental in that growth. 

I vowed not to become maudlin on my last day with the 
program. I returned Claudia to the cottage after supper. 



147 

seated her in a chair, kissed her, and left the living wing. 
Halfway dovm the hall, I turned around and went back for one 
last peek through the window in the door. As she often did 
upon being returned to the cottage, she had walked to the 
window and pressed her hands and face against it. Her in- 
quisitive, innocent expression made it too hard to leave. 
I opened the door, returned her to the chair, and walked out 
again. I looked back and again she was approaching the door. 
I forced myself to leave. 

Claudia Leaves Lilac 

Shortly after I left the STARS Program, the staff was 
informed that grant funds were running out, and the program 
would be terminated within a year. As original projections 
had indicated at least another two years' operating time, we 
had given little thought to the dismantling process. The 
staff immediately set about the task of reducing training 
time for the clients while monitoring to be sure that be- 
havioral losses were minimized. 

The STARS Program had always exclusively served clients 
living in Lilac. When a client was transferred to a higher 
level cottage, we had generally continued training for awhile, 
gradually reducing the amount of time and making ourselves 
available to consult with the new cottage's staff. Most, 
though not all, of the clients fared quite well in their new 
placements. Marsha chose the same tactic with Claudia, recog- 
nizing that it would be dangerous to leave her in Lilac without 



148 



continued training. Lilac w&s crowaed^ filled with ip.ultiply 
handicapped clients-. 'Allowing her to remain there where the 
staff would have little time to spend with her would all but 
guarantee severe behavioral regression. 

Working with the director of the major training depart- 
ment on campus, Marsha arranged a trial period for Claudia at 
Lily, a slightly higher level ICF/MR (Intermediate Care Facil- 
ity for the Mentally Retarded) cottage. The placement was 
significant — ICF/MR cottages are governed by strict federal 
regulations requiring a higher staffing ratio, better physical 
facilities, and more programming time for the clients than are 
found in non-ICF/MR units. During the trial period of several 
weeks, Claudia spent her days at Lily and continued to sleep 
at Lilac. The trial period was successful, and in September, 

1978, Claudia was accepted for residency at Lily. In February, 

1979, all Lily clients were moved so that Lily could undergo 
ICF/MR-directed renovation, scheduled for completion in 19 80. 
Claudia and her Lily peers thus currently reside at Hope Cottage. 
During the Lilac- to-Lily transition period, Marsha, too, left 
the STARS Program, and Lorrie, Mardi, and Maureen assumed res- 
ponsibility for Claudia's training. 

Claudia functions at a somewhat lower level than most of 
her Lily/Hope cottagemates. Many can speak, respond to spoken 
commands, and are toilet trained, ICF/MR regulations specify 
that clients will not wear diapers, and Claudia was therefore 
placed in pants. She is sent to the toilet regularly, and is 
reported to have "few" accidents; Lily/Hope staff estimates 



.49 



are one or fewer per day. Whether this is the result of her 
previous "sending" program, or whether the staff simply sends 
her often enough (she does not eliminate frequently) , we do 
not know, but her toileting behavior is acceptable to the 
cottage personnel. 

ICF/MR clients do not attend the campus cafeteria, but 
Claudia's cafeteria and feeding programs were essential in 
her placement. The cottage staff gradually replaced STARS 
trainers in her feeding program. When Claudia moved to Lily, 
STARS trainers were with her for about two hours per day and 
ten to fifteen meals per week. By January, 1979, STARS time 
was reduced to about 15 minutes following breakfast and lunch 
on weekends, and the Lily/Hope staff was completely responsi- 
ble for the mealtime program. While the cottage staff is not 
currently collecting data, it is insuring that Claudia re- 
tains eating and related skills. For example, clients are 
required to carry their trays into the kitchen after meals, 
and at this task Claudia is quite proficient. Additionally, 
anecdotal information indicates further reduction in the num- 
ber of Claudia's spills while drinking. 

As the STARS workers reduced their time with Claudia, it 
was necessary to find activities to fill the vacancy created 
in her schedule. Mornings were no problem; Julia still 
arrives daily to take Claudia out. Their outings should be 
sufficient to maintain most of Claudia's ambulation skills. 
Afternoons proved to be more difficult. In October, 19 78, 
Claudia was briefly enrolled in the Sunland school, where she 



150 



V7as given generally unstructured gross motor tasks. Her 
enrollment v/as terminated after about a month. The school, 
like STARS, is funded by 89-313 grant monies, and regulations 
forbid clients simultaneously to receive services from two 
89-313-funded organizations. In addition, Claudia's school 
setting did not provide structured, individualized training. 
Not surprisingly, Claudia failed to progress in school. 

By early February, 1979, STARS time with Claudia was 
sufficiently reduced to allow her to re-enter school without 
89-313 funding conflict. It is to be hoped that she will re- 
ceive more structured training than she did previously so 
that she can remain in school. 

Claudia's programming time is not limited to excursions 
with Julia and attending school. She continues to participate 
in STARS field trips, and former STARS staff who have taken 
jobs elsewhere on the campus visit her and take her for off- 
cottage and off-campus outings. 

The chief concern of all of us who worked with Claudia 
is, of course, the rumination. The remaining STARS time is 
devoted to teaching the Lily/Hope staff to monitor the ru- 
mination and maintain the cheek-hold procedure. Since the 
cottage staff does not keep a rumination chart, the success of 
maintaining control will be difficult to judge. Claudia still 
does not ruminate often in the presence of STARS trainers 
(Figure 27, phase N) . Much of the apparent charted increase 
in frequency is an artifact of the charting procedure: fre- 
quencies of zero are charted according to the amount of 



151 



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152 



training time; less training time raises the estimated frequency. 

However, there are also more days now during which Clau- 
dia does ruminate in the presence of a trainer. Cottage per- 
sonnel report that they implement the cheek-hold procedure, 
although not as consistently as did STARS trainers. The 
available data thus suggest that the rumination is increased 
V7hen trainers are not present. Efforts are underway to rec- 
tify the problem. STARS trainers are teaching the Lily/Hope 
staff the importance of consistent intervention. The task is 
not easy. Rumination is common at Sunland and is not a sig- 
nificant problem for many clients who ruminate at a low fre- 
quency and do not evidence weight loss. To the cottage staff, 
Claudia is one such client. She is healthy, does not ruminate 
often, and her weight is stable at 85 to 9 pounds (see 
Figure 6b, p. 48). We observed the problem before among 
staff who began working with the STARS after Claudia's rumina- 
tion was already under control. Now the Lily/Hope staff must 
learn about the consequences of failing to intervene. Their 
learning is the key to the fruition of nearly three years of 
work with Claudia. 

Final Considerations 

Claudia is undergoing major environmental changes. In 
19 75, she was deteriorating in the Lilac environment. She 
thrived in the subsequent Lilac/STARS environment, and con- 
tinued to thrive as she made the transition to the Lily/Hope/ 
STARS milieu. Soon, formal STARS input to her training will 



153 

be. terminate.d. To. da,te, she is doing well. Her new circum- 
stances seem supportive of the changes we induced in her. 

She is required to feed herself and carry her tray, so 
the feeding and related skills should maintain and perhaps 
improve. She will probably retain most of her ambulation 
skills under Julia's auspices and because of her old trainer- 
friends' visits. Hov/ever, formal ambulation training has 
been terminated, and she walks shorter distances, over fewer 
obstacles than she did previously. Some of her skills may 
deteriorate. Her social behaviors may or may not maintain. 
She receives less attention and physical contact than she did 
during intensive STARS training. But she still sees Julia 
and the other grannies, her friends visit, and the higher 
level Lily/Hope clients attend to her more frequently and 
appropriately than did her Lilac peers. A positive sign is 
that she now spends more time sitting on the couch with her 
cottagemates , an improvement over her preference for the Lilac 
day room, floor. 

Her continued wellbeing hinges upon the rumination. Here, 
the data are less definitive. She is currently healthy, but 
more time is needed to determine whether the cottage staff 
can control this salient aspect of Claudia's behavior. 

I continue to worry and wonder what the future will bring 
for Claudia, and I fervently hope for the best for her. We 
taught her many things, but she gave us much more in return. 
She taught us, inspired us, and we came to love her dearly. 
Between visits, I'll miss her. 



CHAPTER III 
DETERMINATION OF VISUAL THRESHOLDI 



Claudia's eyes diverged and informal observations by her 
trainers indicated that her right eye was dominant. At her 
yearly eye examination in 19 77, the doctor confirmed that, 
based upon measures of light refraction, her left eye vision 
was probably considerably poorer than that of her right eye. 
He also commented that adequately assessing the vision of in- 
dividuals functioning at Claudia's level was a difficult task. 
We became interested in the problem and attempted to devise a 
procedure that would relatively rapidly and accurately assess 
Claudia's vision. We realized v/ithin several weeks that, at 
least for Claudia, the procedure was not a quick, convenient 
one. We continued to pursue the problem, however, as we were 
curious to discover whether we could calculate any sort of 
visual threshold measure. Claudia's extensive training sched- 
ule allowed us ample time to spend the several minutes per day 
necessary to conduct the visual training and testing. 

Assessing the vision of severely retarded, handicapped 
individuals is difficult, primarily because many such in- 
dividuals do not respond to verbal instructions. In addition. 



iThe author wishes to thank Dr. C. K. Adams for his en- 
couragement and consultation throughout this project. His 
assistance was indispensable in developing the final experi- 
mental procedure. 

154 



155 

these individuals may be easily distracted, and their handicaps 
can severely limit the nature of the response used for assess- 
ment (Faye, 1968; Langley & DuBose, 1976). The problem is 
particularly important since visual impairment frequently 
accompanies retardation and other handicaps (Blackhurst & 
Radke, 1968; Wolf & Anderson, 1973; Langley & DuBose, 1976). 

Available techniques for assessing handicapped popula- 
tions generally require responses that are too complex for 
profoundly retarded individuals. The responses are commonly 
centered around choosing or matching various toys, simple 
shapes, and pictures (Faye, 1968; Lippman, 1969). For lower 
functioning individuals, operant assessment procedures are 
more promising since the response is usually simple to exe- 
cute and primary reinforcement insures that the subject will 
emit enough responses to be assessed. Sidman and Stoddard 
(1967; and Stoddard & Sidman, 1971), for example, were able 
to obtain visual acuity measures from retarded subjects by 
establishing a circle-ellipse discrimination and gradually 
making the ellipse more circular, Macht (1971) developed 
a procedure in which lever presses caused a circle to rotate. 
Subjects learned to upright a Snellen E printed on the circle, 

Newsom and Simon (19 77) reported a simpler procedure. 
The response involved walking dov;n one of two short passage- 
ways and touching a stimulus card at the end of the passage- 
way. One passageway contained S+ , originally a card with 
vertical black and white stripes, faded in two steps to a 
Snellen E rotated 9 0° (pointing downward) . The other 



156 



passageway contained S-, originally a blank card, faded in 18 
steps to a backwards Snellen E. Praise and an edible rein- 
forcer were delivered for each correct choice; the child was 
told to sit down each time he or she entered the wrong pas- 
sageway. Progressively smaller stimulus pairs were used to 
determine visual resolution acuity. Of eleven nonverbal, 
autistic and schizophrenic Ss_, eight were successfully 
trained and tested, each requiring no more than three hours 
(one to three sessions) . The remaining three S_s failed to 
make a horizontal-vertical stripe discrimination during 
training and could not be tested. 

Method 

Training the Basic Response 

We chose depositing blocks in a can as the basic response. 
When we began training we were not sure what the final test 
stimuli would be. We preferred instead to postpone this de- 
cision until we isolated a visual dimension to which Claudia 
would reliably respond and that we could accurately quantify 
in increments small enough to obtain a discrimination mea- 
sure. We decided only that the task would involve choosing 
one of two blocks over repeated trials. 

We trained Claudia to pick up a 2.54-cm^ Cone cubic 
inch) wooden block and deposit it in an empty peanut butter 
can (institutional size, 17,78 cm diameter). Training re- 
quired three days, ten minutes per day. Claudia initially 
reached for the block and picked it up when it was placed in 



157 



front of her; the trainer merely guided Claudia's hand over 
the can and induced her to release the block. She received 
a spoonful of food for each block deposited. During the 
first day, Claudia needed assistance of this nature on ap- 
proximately one block per minute, while she independently 
deposited about four blocks per minute. By the third day, 
she needed assistance with only two blocks (0.2 blocks per 
minute) and independently deposited seven blocks per minute. 
She used her right hand almost exclusively during training 
and throughout the study. 

We next constructed the experimental apparatus, a 
45.72-cm length of two-by-four board, to which we glued two 
small plastic cups, 15.24 cm apart. The cups were filled 
with Play Dough so that each wooden block would protrude 
1.59 cm above the cup rim.. The entire apparatus was painted 
gray. 

The trainer and Claudia sat on the floor facing each other 
across a small coffee table, on which the trainer placed the 
apparatus, and to Claudia's right, the peanut butter can. 
The trainer placed one block at a time into one of the cups, 
alternating cups. During the first day, Claudia repeatedly 
grabbed both block and cup, ripped the cups off the board. 
We fortified the apparatus and repainted it. The next day we 
began with the block on the tabletop, next to the apparatus. 
Over ten trials Cone trial = depositing one block in the can) , 
we moved the block from the tabletop, onto the apparatus (but 
not in the cups), and finally into the cups. During the 



158 



remainder of the session, she deposited 55 blocks in ten 
minutes, 40 seconds, grabbing the cup 20 times in the process. 
The frequency and apparent (but unmeasured) force with which 
she grabbed the cup decreased during the session and were no 
longer a problem at the end of the session. The problem did 
not reappear during the course of the study. 

Discrimination Training 

Discrimination training and testing were conducted in 
Lilac's lounge. Sessions began between 4:00 and 4:30 p.m. 
and usually lasted seven to ten minutes. Claudia's schedule 
usually permitted three to five sessions per week. The ses- 
sions V7ere conducted before her other afternoon training ses- 
sions to minimize fatigue and maximize the effects of the 
reinforcer. The window curtains were closed during the 
sessions so that the only light source was overhead fluores- 
cent lighting. Light level on the apparatus was 16 foot- 
candles (measured with light meter installed in Honeywell 
Pentax Spotmatic camera) , During the first half of the train- 
ing phase, Claudia was seated at the coffee table, as described 
above; during the second half of training and throughout test- 
ing, she was seated in the relaxation chair. She m.aintained 
a constant posture in the relaxation chair, head slightly 
tilted forward, eyes 40 - 45 cm from the stimulus blocks. 
Other trainers and clients, staff, and visitors were occasional- 
ly in the lounge but were apparently not distracting; Claudia 
rarely looked up v;hile the sessions were in progress. 



159 



The discrimination task involved lifting and depositing 
in the can one of two blocks (S+,. S-) presented simultaneously 
in the apparatus cups. The trainer tallied correct and in- 
correct responses on a record sheet which indicated whether S+ 
was placed in the right or left cup. Sessions consisted of 40 
trials Cincreased to 50 trials during the final testing phase) 
of random right and left placements. The randomdzation was 
modified to insure an equal number of right and left place- 
ments and that S+ was never placed' on the same side more than 
four times in succession. The trainer timed each session with 
a stopwatch, beginning the timing when the first pair of 
stimulus blocks was presented and ending the timing when the 
final block v/as deposited in the can. The watch did not run 
during timeout periods (see below) , Data were thus available 
regarding the numJDer and frequency of S+ and S- choices, as 
well as regarding conditional probabilities (probability of 
choosing S+ in right versus left cup, etc.). 

The first training phase involved discriminating solid 
white (S+) and solid black (S-) blocks. Each time Claudia 
deposited the S+ block in the can, she was given a spoonful 
of food; if she picked up the S- block, the trainer took it 
away before she could deposit it and removed the apparatus 
(timeout, TO) for 15 seconds. Immediately follov/ing either 
food delivery or 15 second TO, the next pair of blocks was 
presented. Thus, although the session consisted of discrete 
trials, or block presentations, the trials occurred as rapidly 
as Claudia's and the trainer's behavior permitted, rather than 



160 



on a time-based schedule. At first Claudia chose S+ more 
frequently than S-, but the discrimination deteriorated 
rapidly (Figure 28, phase A) 1. 

A large part of the problem appeared to be that Claudia 
was "grabby" between trials. As soon as she deposited a block 
and received a reinforcer, she began reaching for the appara- 
tus and would take the first block inserted into a cup. We 
used a cardboard screen for several days in an effort to 
alleviate the problem. Although her performance improved, 
(phase B) , the grabbing continued, this time directed at the 
screen. When the trainer removed the screen, Claudia fre- 
quently took the block nearer her hand. We eliminated the 
screen and solved the problem by instituting a "distracting 
response" (phase C) . Before each trial, the trainer placed 
an orange wooden block (one cubic inch) in front of the 
apparatus. While Claudia deposited the block in the can, the 
trainer arranged the stimulus blocks. A trial therefore con- 
sisted of depositing one orange and one stimulus block. No 
training was required to induce Claudia to deposit the orange 
blocks. This arrangement remained in effect for the duration 
of the study. 



-'-While Fig. 2 8 records the frequency of St and S- choices, 
percent correct is readily derived. Where S- responses are 
indicated, percent correct is obviously 100. In other cases, 
percent correct is calculated by obtaining the ratio of S+ to 
S- choices; on the logarithm.ic frequency scale, the ratio is 
the distance between S+ and S- frequencies. Percent correct = 
(ratio) T (ratio + 1). For example, if S+ rate = 6 per min, 
and S- rate = 2 per min., ratio =6^2=3, and percent cor- 
rect = 34-4 = 0.75, or 75%. 



161 




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163 

Although the grabbing was greatly reduced, Claudia 
reached for the stimulus block on her right in a dispropor- 
tionately high number of trials. The side preference had 
existed since the start of training, but v/orsened shortly af- 
ter we introduced the distracting response. It is not clear 
whether the distracting response and the preference were 
related. The side preference is illustrated in Figure 29a, 
the probability of a correct response when S+ was in right 
versus left cup, and Figure 29b, the probability with which 
Claudia reached for the right block regardless of whether 
the block was S+ or S-. When Claudia reached for the right 
block nearly 100% of the time, we placed the can on her left 
side. Although the preference temporarily disappeared, it 
soon returned (Figure 28, phase D ; Figures 29 a,b) . We now 
glued the S- block into one of the cups and rotated the entire 
apparatus to effect right and left presentations. The side 
preference disappeared permanently (Figures 29 a,b) . 

When we glued the S- block, we removed the TO contingency 
since Claudia obviously could not lift the incorrect block. 
Instead, we let her pull at the S- block and correct her error; 
she received reinforcement for depositing the S+ block whether 
or not she had first pulled at the S- block. Her performance 
gradually deteriorated (Figure 28, phase E) . We altered the 
contingencies; depositing S+ still resulted in reinforcement, 
but the apparatus was removed for 15 seconds (TO) as soon as 
Claudia's hand touched S-. After a week her performance 
began improving (phase F) . 



164 




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165 

When she was responding to S- about 0.2 5 times per minute 
(about three responses per 40 trials) , we reversed S+ and S- 
so that S+ was nov/ the black block. S- , the white block, was 
covered entirely by gray tape. The same contingencies were in 
effect; depositing the black block resulted in reinforcement 
and touching S- (actually the gray tape) resulted in a 15 
second TO. Although the S- block V7as not even visible, she 
reached frequently at first for the gray tape (phase G) . She 
rapidly learned to pick up the black block, and we removed the 
tape from S-. We did not glue the white block, however. In- 
stead, if she picked it up, it was taken away from her and 
a 15 second TO ensued, (same procedure as that of phase A, 
except S+ = black and S- = white) . Her performance rapidly 
degenerated (phase H) . 

Since Claudia had learned so quickly to avoid the block 
with gray tape, we retaped the v/hite block (phase I) . This 
time, however, the tape was a strip 1.59 cm thick, running 
from the lip of the cup over the top of the block and down to 
the lip on the opposite side, so that the tape formed a verti- 
cal gray stripe over the block. We then decreased the thick- 
ness of the tape in steps, 0.64 cm, 0.32 cm. and 0.16 cm. 
At 0.16 cm we colored the tape black. Apparatus removal for 
15 seconds contingent upon touching S- was reinstated. The S- 
block was glued during this phase, as the thin tape strip could 
not prevent her from removing the block if she grabbed it 
firmly before the trainer could remove the apparatus. 

We finally realized that the tape could be used to estab- 
lish a discrimination for threshold measurement. A white 



166 

block with black tape was still S-, and S+ became a plain 
white block (phase J) . We began conducting sessions in the 
relaxation chair and removed the part of the tape fastened to 
the lip of the cup. Instead, the tape ran over the top of the 
block and down its sides. Claudia performed almost errorlessly 
(phase K) . We gradually removed the tape from the sides of the 
block (phase L) , running it 1,27 cm down each side, then just 
barely over the top edges of the block, finally shortening and 
widening the tape until it was roughly hexagonal, 1,27 cm long 
and 0.79 cm wide, on top of the block. We also removed the 
glue and replaced it with Velcro patches to hold S- firmly 
in place. Nonstick material was placed on S+ blocks to equate 
the height of S+ and S-. Thus, S- could be moved from cup 
to cup between trials, eliminating the possibility that 
Claudia could be responding to some aspect of the cup in 
which S- was placed. We were ready to begin testing. 

Testing, Retraining, and Retesting 

We prepared the series of test stimuli. A v/hite block 
continued to serve as S+, and the S- series was a set of nine 
blocks, each white with a black (India ink) circle in the top 
center of the block. The circle diameters were: 0.56 cm 
(7/32 inch), 0.48 cm (3/16), 0,40 cm (5/32 inch), 0.32 cm 
(1/8 inch), 0.24 cm (3/32 inch), 0.16 cm (1/16 inch), 0.12 cm 
(3/64 inch), 0.08 cm (1/32 inch), and 0.04 cm (1/64 inch). ■ 
The stimuli are henceforth designated 7, 6, 5, 4, 3, 2, 1, 0.5. 
All S- blocks v/ere equipped with Velcro patches. 

We switched to a VR2 schedule of reinforcement, • 



16 7 

anticipating that Claudia would begin making errors as the 
stimuli approached her threshold; all errors still resulted in 
a 15 second TO (phase M) . We began using only block 7 and over 
several days introduced blocks 5, 5, and 4. The same stimulus 
was presented over four consecutive trials, and the order of 
stimuli was mixed (e.g., four 7's, four 4's, four 6's, etc.). 
The procedure was thus a variation of the constant-stimulus 
and constant-stimulus difference methods popular in psycho- 
physics (Christman, 1971) . 

Each session v/as 40 trials as was the case during train- 
ing. As Claudia was making few errors at any of these S- 
values , we eliminated the 7 and 6 blocks and inserted eight 
trials with the 3 block, then eight trials with the 2 block. 
On the day we added the 2 block, her error frequency was 1. 8 
per minute; the previous day it had been 0,9 per minute. 
Most of the errors occurred on the 2 block. The next day her 
error frequency rose again, and again most of the errors 
occurred on the 2 block. The following day, although she 
made more correct than incorrect responses, the discrimination 
was largely lost, as errors appeared at all S- values. We 
had probably added the smaller S- dots too rapidly. 

We consequently undertook retraining (phase N) . We re- 
turned to reinforcing every correct response and used only 
blocks 5, 5, and 4. We did not regain control, and therefore 
eliminated blocks 5 and 4 and added an S- block with a black 
tape patch similar to the tape patches used prior to testing. 
This was sufficient to reestablish control, and we eliminated 
the tape patch, returned to a VR2 reinforcement schedule, and 



168 

included trials using blocks 5 and 4. We increased the nuniber 
of trials per session to 60 and eliminated the 6 block. We 
were again ready to test, i.e., add blocks 3, 2, 1.5, 1, and 
0.5. The entire retraining process had taken five weeks. 

During the second testing period (phase C) , which lasted 
six and a half weeks, we added the smaller S- blocks at a 
slower rate than we had previously. In addition, we presented 
a given S~ only twice in succession, taking care to present 
larger dots immediately before and after the smaller ones. 
Claudia's error rate never exceeded 1.5 per minute. During 
the final several weeks of testing, each session consisted of 
30 presentations of the 5 block, six 2's, eight 1.5's, eight 
I's, and eight 0.5's (the 3 and 4 blocks were eliminated as 
Claudia nearly always responded correctly; the 5 block re- 
mained to insure that she did not lose the discrimination) . 

Testing was discontinued at the end of May due to major 
structural changes in the STARS Program, Consequently, thresh- 
old values were never determined for right and left eyes 
separately. 

Results 

The results of the second testing series (phase 0; 4/7/78- 
5/19/78) are displayed in Figure 30. The data are divided 
into four curves according to the dates listed on the figure. 
The divisions were chosen as follows: Triangles represent 
data taken v/hen blocks 5, 4, 3, 2, 1, were used; squares 
represent data taken on all seven blocks; filled circles are 



169 



PERCENT 
CORRECT 



S - 

TESTIWG 
DATES 

WO. TRIALS 



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X Hi 







.04 J»i 



roTM. 


IM 


1*7 


lis 


ise 


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9& 


■«/«»-*«» 


16 


17 


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Fig. 30. Percent correct choices as a function of diameter 
of S- dot. The four curves represent data taken during 
successive periods of testing, as indicated in the key, 
above. The columns containing numbers of trials correspond 
to the S- dot sizes under which the columns appear. 



170 

data taken on all seven blocks, but while the 4 block was being 
eliminated, open circles represent data taken on blocks 5, 2, 
1.5, 1, 0.5. 

The curves move generally upward through time, indicating 
that Claudia was becoming progressively more sensitive to the 
smaller stimuli. However, the last two curves are extrem.ely 
close; she was probably discriminating maximally. Since the 
procedure involved choosing one of two blocks, 50% correct 
is not an appropriate threshold criterion. Instead, the 
threshold line is taken to be 75%. The line passes precisely 
through the 0.0 8 cm value for the last of the curves; her 
threshold is therefore 0.0 8 cm. At 42.5 ± 2.5 cm from 
Claudia's eyes, the threshold stimulus subtended 0.10 8 t 
0.006° , or 6.47 + 0.40 min of visual angle. 

Using the 6.47 min of visual angle subtended by the 
threshold stimulus, it is possible to approximate the familiar 
Snellen acuity ratio. The Snellen ratio for "normal" vision, 
20/20, indicates that the subject can resolve a separable angle 
of one min; 20/40 means that the subject requires twice the 
norm.al separation, or two min; 20/200 is a ten-min angle, 
and so on. Since Claudia reliably detected a stimulus sub- 
tending 6.47 min of angle, the approximate Snellen ratio is 
20/130, For the purposes of comparison, in most states, an 
individual must have corrected vision of 20/40 or better to 
obtain a driver's license; persons with corrected vision of 
less than 20/200 are considered legally blind (.Massachusetts 
Department of Medical Affairs, personal communication) . 



171 



The ratio calculated for Claudia must be interpreted 
cautiously, however. Resolution acuity, which the Snellen 
ratio measures, refers to the subject's ability to detect a 
separation between the components of a stimulus. For example, 
all segments of the Snellen "E" are one min in width, and 
each segment is separated by a one-min space. In comparison, 
Claudia was detecting the presence/absence of a single- 
component stimulus, a circle. To obtain a more accurate es- 
timate of the Snellen ratio for Claudia, we would have had to 
use multi-component stimuli, for example, two horizontal 
stripes and two vertical stripes. 

Discussion 

Although we successfully established a visual threshold 
for Claudia, the study was a failure in several respects. The 
original aim was to devise a rapid (several days to several 
weeks) means of measuring visual acuity. The project lasted 
just over a year and produced a measure of visibility acuity 
(presence/absence of a stimulus) that can only tenuously be 
converted to the common measure of visual functioning, reso- 
lution acuity. The procedure would presumably have taken 
less time with higher level clients and would also likely re- 
quire less time to replicate with a client of Claudia's level, 
based on what we learned from the present study. However, the 
procedure devised by Newsom and Simon, discussed in the intro- 
duction, requires less time and directly produces a resolu- 
tion acuity ratio. Thus, Newsom and Simon's procedure would 



17: 



proba,l3ly b,e the method of choice with higher functioning 
clients, 

For individuals functioning at Claudia's level, those 
who would not likely be testable with other procedures, more 
data are required regarding the usefulness of the present 
procedure. By how much could the procedure be shortened? 
What problem.s might be involved in testing each eye separately? 
We successfully trained Claudia to wear a patch on either 
eye in anticipation of the present study, but whether she 
would have performed the discrimination task, particularly 
with her dominant eye covered, is a matter of speculation. 
The problems encountered during the study would certainly 
lead one to suspect that testing the weaker eye would have 
produced further problems, 

A different line of questioning addresses the useful- 
ness of detailed visual assessment for lower functioning in- 
dividuals. In the absence of procedures such as those dis- 
cussed in the introduction, an opthamologist ' s examination, 
requiring no behavior from the subject other than keeping the 
eyes open, reveals gross impairments or physical damage to 
the eyes. How much further information is useful or necessary? 
Claudia functioned well enough in her regular training ses- 
sions. How much, if at all, better would she have fared were 
her vision assessed and corrected? Would she have learned to 
walk more rapidly with corrected vision, especially in pro- 
grams such as step-climbing and obstacles, which required her 
to discriminate edges and contours? The answers to such 



173 

questions require a means of testing and correcting vision. 
The present study is a beginning. 

The study was also useful in another sense. All of us 
involved in it learned much about the experimental analysis 
of behavior. We were tempted to abandon the study many times, 
particularly since it was not an integral part of Claudia's 
training. However, the problem intrigued us, and the sessions 
required little time per day. We were disappointed that we 
did not achieve our original aims, but we were not sorry that 
we attempted the project. 



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BIOGRAPHICAL SKETCH 

William Hartman was born April 30, 1950, in Chicago. He 
grew up in the Chicago area and graduated in 19 6 8 from Deer- 
field High School, Deerfield, Illinois. 

Mr. Hartman majored in psychology at Oberlin College 
(Oberlin, Ohio) , where he received his Bachelor of Arts degree 
in 19 72. In late 19 72, he entered the graduate psychology 
program at the University of Florida. He studied the experi- 
mental analysis of behavior with Dr. H, S, Pennypacker, 
stressing applications in higher education, with children, and 
with developmen tally disabled individuals. He received his 
master's degree in 19 75. 

In 1978, while continuing his graduate studies with Dr.. 
Pennypacker, Mr. Hartman assumed the positions he currently 
holds: chief psychologist at the Eunice Kennedy Shriver 
Center for Mental Retardation in Waltham, Massachusetts, and 
visiting assistant professor of psychology at Northeastern 
University. He provides psychological and behavioral assess- 
ments and consultation in a community clinic for the develop- 
mentally disabled and teaches in a graduate program regarding 
behavior analysis/retardation, 

Mr, Hartman received his Ph.D. in psychology from the 
University of Florida in 1979. 



18; 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 

presentation and is fully adequate, in scope and._quality , 

as a dissertation for the degree* of Doctpr' of Philo's-aphy. 




"Henry S'. Pennyj^acker^''' Chairman 
Professor of Psychology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 



.-r? 



n 



<^/ai^ fy^Mri 



\ 



Marc Branch 

Associate Professor of Psychology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




Mark Goldstein \ 

Associate Professor of Psychology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




)La^^\-^^^ 




Jam^s Johnston j 

A^_s;siciate Professgr of Psychology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 




T 



^ / 



Dorothy Nevill 



Associate Professor of Psychology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, 
as a dissertation for the degree of Doctor of Philosophy. 



r 



V, 



..^AiaQvVV ^ YvaavXa-\ 



JohnX Newell 

Pro^ssor of Foundations of 

Education 



This dissertation was submitted to the Graduate Faculty 
of the Department of Psychology in the College of Liberal 
Arts and Sciences and to the Graduate Council, and was ac- 
cepted as partial fulfillment of the requirements for the 
degree of Doctor of Philosophy. 

December, 19 79 



Dean, Graduate School